Nclex Made Incredibly Easy-Respiratory Questions

3. A 165-lb client weighs 75 kg (2.2 lb = 1 kg). 20 units × 75 kg × 1 hour = 1,500 units/hour.

A 165-lb client with a pulmonary embolus is ordered to receive heparin 20 units/kg/hour by I.V. infusion. How many units of heparin should he receive each hour? 1. 1,000 2. 1,200 3. 1,500 4. 1,700

4. These are classic signs and symptoms of a client with emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase and has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. Based on the assessment findings, the nurse suspects that the client is experiencing which condition? 1. Acute respiratory distress syndrome (ARDS) 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

1. In pulmonary edema, the most frequently heard sounds are crackles. Decreased breath sounds and inspiratory and expiratory wheezing are associated with asthma, and rhonchi are heard when there's sputum in the airways.

A client experienced smoke inhalation and developed pulmonary edema. The nurse auscultates the client's breath sounds and anticipates hearing which of the following? 1. Crackles 2. Decreased breath sounds 3. Inspiratory and expiratory wheezing 4. Upper airway rhonchi

3. Pleuritic pain is caused by the inflammatory reaction of the lung parenchyma. The pain isn't associated with costochondritis, MI, or referred pain from the pelvis to the chest.

A client has been diagnosed with a pulmonary embolism and begins to experience chest pain. The client asks the nurse what is causing the pain. The most appropriate response by the nurse is: 1. costochondritis. 2. myocardial infarction (MI). 3. inflammatory reaction. 4. referred pain from the pelvis to the chest.

3. A pulmonary angiogram is used to definitively diagnose a pulmonary embolism. A catheter is passed through the circulation to the region of the occlusion; the region can be outlined with an injection of contrast medium and viewed by fluoroscopy. This shows the location of the clot as well as the extent of the perfusion defect. ABG levels can define the amount of hypoxia present. A chest X-ray can't provide a definitive diagnosis of pulmonary embolism. The (V/Q) scan can report whether there's a (V/Q) mismatch present and define the amount of tissue involved.

A client is suspected of having a pulmonary embolism and asks the nurse how the doctor will definitively determine the diagnosis. The nurse anticipates that the physician will order: 1. arterial blood gas (ABG) analysis. 2. chest X-ray. 3. pulmonary angiogram. 4. ventilation-perfusion (V/Q) scan.

3. The umbrella filter is placed in a client at high risk for the formation of more clots that could potentially become pulmonary emboli. The filter breaks the clots into small pieces that won't significantly occlude the pulmonary vasculature. The filter doesn't prevent further clot formation and doesn't release anticoagulants. The filter doesn't collect the clots, because if it did, it would have to be emptied periodically, causing the client to require surgery in the future.

A client with a pulmonary embolism is scheduled to have an umbrella filter placed in the vena cava. The nurse determines that teaching has been effective when the client states: 1. "The filter prevents further clot formation." 2. "The filter collects clots so they don't go to the lung." 3. "The filter breaks up clots into insignificantly small pieces." 4. "The filter contains anticoagulants that are slowly released, dissolving any clots."

1. If the client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won't solve the problem. The client won't get used to the tube because it's the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.

A comatose client requires a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. The priority intervention by the nurse would be? 1. Remove the airway and insert a shorter one. 2. Reposition the airway. 3. Leave the airway in place until the client gets used to it. 4. Remove the airway and attempt suctioning without it.

4. It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these clients to need intubation and mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The vaccines have no effect on bronchodilation or respiratory rate.

The community health nurse is administering Pneumovax and flu vaccinations to clients with asthma, chronic bronchitis, and emphysema. A client asks the nurse why these vaccines are recommended. What is the best response by the nurse? 1. "These vaccines are recommended for all clients." 2. "These vaccines produce bronchodilation and improve oxygenation." 3. "These vaccines help reduce the tachypnea these clients experience." 4. "Respiratory infections can cause severe hypoxia and possibly death in these clients."

3. The only way to reexpand the lung is to place a chest tube on the right side so the air in the pleural space can be removed and the lung reexpanded. Antibiotics and bronchodilators would have no effect on lung reexpansion, nor would the hyperbaric chamber.

The nurse anticipates that the priority treatment for a client with spontaneous pneumothorax is: 1. antibiotics. 2. bronchodilators. 3. chest tube placement. 4. hyperbaric chamber.

4. As many as 90% of clients with lung cancer smoke cigarettes. Cigarette smoke contains several organ-specific carcinogens. There may be a genetic predisposition for the development of cancer. Occupational hazards such as pollutants can cause cancer. Pipe smokers inhale less often than cigarette smokers and tend to develop cancers of the lip and mouth.

The nurse is teaching a client about lung cancer. The nurse determines teaching was effective when the client states the primary cause of lung cancer is: 1. genetics. 2. occupational exposures. 3. smoking a pipe. 4. smoking cigarettes.

4. Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions typically don't affect the respiratory system.

Which client would be considered to be at the highest risk for respiratory failure? 1. A client with breast cancer 2. A client with cervical sprains 3. A client with a fractured hip 4. A client with Guillain-Barré syndrome

3. Nonallergic asthma doesn't have an easily identifiable allergen and can be triggered by the common cold. Asthma caused by emotional reasons is considered to be in the extrinsic category. Allergic asthma is caused by dust, molds, and pets—easily identifiable allergens. Mediated asthma doesn't exist.

A client recently experienced a common cold and a subsequent asthma attack. Based on the assessment findings, the nurse determines that the client is experiencing which type of asthma? 1. Emotional 2. Allergic 3. Nonallergic 4. Mediated

2. The client having an acute asthma attack needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First, resolve the acute phase of the attack, and then obtain a full medical history to determine the cause of the attack and how to prevent attacks in the future. It may not be necessary to place the client on a cardiac monitor because he's only 19 years old, unless he has a past medical history of cardiac problems.

A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears in acute respiratory distress. What is the most important action for the nurse to take? 1. Take a full medical history. 2. Give a bronchodilator by nebulizer. 3. Apply a cardiac monitor to the client. 4. Provide emotional support to the client.

3. The client probably can't be roused from the combination of pills and alcohol he has taken. This has probably caused him to breathe shallowly, which, if not monitored closely, could lead to respiratory arrest. The nurse wouldn't expect to find tachypnea and doesn't have enough information about which drugs he took to expect muscle spasms or hyperreflexia.

A 19-year-old client went to a party, took "some pills," and drank beer. He is brought to the emergency department because he won't wake up. When assessing the client, the nurse would anticipate which of the following? 1. Hyperreflexive reflexes 2. Muscle spasms 3. Shallow respirations 4. Tachypnea

1. Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest X-ray and an ECG, but a physician must order these tests. Unless a cardiac source for the client's pain is identified, he won't need an echocardiogram.

A 24-year-old client comes into the clinic complaining of sudden-onset, right-sided chest pain and shortness of breath. The nurse is assessing the client and determines that the most important intervention to implement is: 1. auscultation of breath sounds. 2. chest X-ray. 3. echocardiogram. 4. electrocardiogram (ECG).

3. Because of his extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. Clients with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough or peripheral edema.

A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this assessment, the nurse suspects the client may be experiencing: 1. acute respiratory distress syndrome (ARDS). 2. asthma. 3. chronic obstructive bronchitis. 4. emphysema.

3. The client may have a left pneumothorax from the trauma he experienced. Auscultation would reveal rhonchi with bronchitis, bronchial breath sounds with pneumonia, and rhonchorous breath sounds with TB.

A 60-year-old client was in a motor vehicle accident. He is brought to the emergency department by the paramedics. During the assessment, the client complains of difficulty breathing and chest pain. Auscultation of lung fields notes absent breath sounds in the left upper lobe. The nurse interprets this information as indicating which condition? 1. Bronchitis 2. Pneumonia 3. Pneumothorax 4. Tuberculosis (TB)

2. Semi-Fowler's position (with the head of the bed elevated 30 degrees) promotes optimal lung expansion. A prone position (lying on the abdomen) improves oxygenation in a client with acute respiratory distress syndrome who's receiving mechanical ventilation by recruiting new alveoli in the posterior region of the lung. Reverse Trendelenburg's position (in which the entire bed is raised to a 45-degree angle) may improve lung expansion but is less effective than semi-Fowler's position. Supine positioning (lying flat on the back) doesn't aid lung expansion.

A 67-year-old client is in respiratory distress after being admitted with an exacerbation of chronic obstructive pulmonary disease. To promote optimal lung expansion, the nurse should position the client: 1. prone. 2. semi-Fowler's. 3. reverse Trendelenburg's. 4. supine.

4. Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. It's unlikely that the client has developed asthma or bronchitis without a previous history. He could develop atelectasis, but it typically doesn't produce progressive hypoxia.

A 69-year-old client develops acute shortness of breath and progressive hypoxia requiring mechanical ventilation after repair of a fractured right femur. The nurse determines that the hypoxia was probably a result of which condition? 1. Asthma attack 2. Atelectasis 3. Bronchitis 4. Fat embolism

1. Based on the child's history and symptoms, acute asthma is the most likely diagnosis. He's unlikely to have bronchial pneumonia without a productive cough and fever, and he's too young to have developed COPD and emphysema.

A 7-year-old who recently had a cold is brought to the emergency department. The nurse assesses the child and finds he is afebrile, has a respiratory rate of 36 breaths/minute, and has a nonproductive cough. The nurse suspects that the child may be experiencing what? 1. Acute asthma 2. Bronchial pneumonia 3. Chronic obstructive pulmonary disease (COPD) 4. Emphysema

4. Reduction in vital capacity is a normal physiological change in the older adult. Other normal physiological changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase in residual volume.

A 76-year-old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. The nurse determines that this assessment finding indicates: 1. increased elastic recoil of the lungs. 2. increased number of functional capillaries in the alveoli. 3. decreased residual volume. 4. decreased vital capacity.

1. The most common etiology of pulmonary embolism is thromboembolism from a distant site, particularly from deep veins of the legs and pelvis (90% to 95%). Moreover, the immobilization used to treat DVT is an additional clinical risk factor for pulmonary embolism. Pneumothorax and pulmonary edema aren't complications of DVT. Although immobility also places the client at risk for pneumonia, the risk isn't as great for this client.

The care plan for a 42-year-old client with deep vein thrombosis (DVT) includes monitoring the client for complications. The nurse determines that the client is at highest risk to develop: 1. pulmonary embolism. 2. pneumothorax. 3. pulmonary edema. 4. pneumonia.

2. The (V/Q) scan provides information on the extent of occlusion caused by the pulmonary embolism and the amount of lung tissue involved in the area not perfused.

A client is scheduled to have a ventilation-perfusion (V/Q) scan performed and asks the nurse to explain the tests. The nurse tells the client that the test is frequently done to diagnose a pulmonary embolism and provide information about the: 1. amount of perfusion present in the lung. 2. extent of the occlusion and amount of perfusion lost. 3. location of the pulmonary embolism. 4. location and size of the pulmonary embolism.

3. Fever, productive cough, and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia, with worsening hypoxia over time if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI, so this client most likely isn't having an MI. The client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse's suspicions.

A 78-year-old client is admitted with a diagnosis of dehydration and change in mental status. He's being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103.7° F (39.47° C), a cough producing yellow sputum, and pleuritic chest pain. The nurse suspects this client may have developed: 1. acute respiratory distress syndrome (ARDS). 2. myocardial infarction (MI). 3. pneumonia. 4. tuberculosis (TB).

2. The nonrebreather mask delivers oxygen concentrations of 80% to 100%. It's reserved for emergency situations. A partial rebreather mask delivers concentrations of 60% to 80%. A nasal cannula delivers oxygen at flow rates of 1 to 6 L/minute. A flow rate of 4 L/minute delivers an oxygen concentration of 36%; a rate of 6 L/minute delivers an oxygen concentration of 44%.

A 79-year-old client suddenly develops pulmonary edema. The physician prescribes furosemide (Lasix), 40 mg I.V., and use of a nonrebreather mask. The nurse is aware that the mask will provide the client an oxygen concentration of: 1. 60% to 80%. 2. 80% to 100%. 3. 36%. 4. 44%.

3. To prevent the client from sucking air into the pleural space and causing a pneumothorax, an occlusive dressing should be put over the hole where the tube came out. The physician should be called and the client checked for signs of respiratory distress. Positioning the client on either the left or right side won't make a difference. It isn't advisable for the physician to reinsert the old tube because it's no longer sterile.

A client alerts the nurse that his chest tube has accidentally been removed. What is the most appropriate action by the nurse? 1. Position the client on his left side. 2. Position the client on his right side. 3. Apply an occlusive dressing over the site. 4. Reinsert the chest tube that fell out.

2. Bronchodilators would help open the client's airway and improve his oxygenation status. Beta-adrenergic blockers aren't indicated in the management of asthma because they may cause bronchospasm. Obtaining laboratory values wouldn't be done on an emergency basis, and having the client lie flat in bed could worsen his ability to breathe.

A client diagnosed with asthma is experiencing an anaphylactic reaction to a drug. After administering initial emergency care, the nurse would: 1. administer beta-adrenergic blockers. 2. administer bronchodilators. 3. obtain serum electrolyte levels. 4. have the client lie flat in the bed.

2. First, the nurse should attempt to rouse the client because this should increase the client's respiratory rate. If available, a spot pulse oximetry check should be done and breath sounds should be checked. The physician should be notified immediately of the findings. He'll probably order ABG analysis to determine specific carbon dioxide and oxygen levels, which will indicate the effectiveness of ventilation. Reflexes and heart sounds will be part of the more extensive examination done after these initial actions are completed.

A client has a respiratory rate of 4 breaths/minute. The most important assessments for the nurse to obtain would be? 1. Arterial blood gas (ABG) and breath sounds 2. Level of consciousness and a pulse oximetry value 3. Breath sounds and reflexes 4. Pulse oximetry value and heart sounds

4. Thoracic kyphoscoliosis causes lung compression, restricts lung expansion, and results in more rapid and shallow respiration. It doesn't improve lung expansion because of the compression. It also doesn't cause obstruction or reduce alveolar compression during expiration.

A client has been diagnosed with thoracic kyphoscoliosis. The nurse is aware that this will have what effect on the client's lungs? 1. Improve overall expansion 2. Obstruct deflation 3. Reduce alveolar compression during expiration 4. Restrict expansion

3. PEEP delivers positive pressure to the lung at the end of expiration. This helps open collapsed alveoli and helps them stay open so gas exchange can occur in these newly opened alveoli, improving oxygenation. The bronchioles don't participate in gas exchange except to act as a conduit for inspired and expired air. The walls are rigid enough that they generally don't collapse. PEEP doesn't directly add pressure to the lung tissue or provide more oxygen to the client.

A client has been intubated and placed on a ventilator with positive endexpiratory pressure (PEEP). The nurse anticipates that the primary function of PEEP will be to: 1. provide more oxygen to the client. 2. open up bronchioles and allow oxygen to get in the lungs. 3. open up collapsed alveoli and help keep them open. 4. add pressure to the lung tissue, which improves gaseous exchange.

4. Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake.

A client has been placed on a high level of oxygen. The nurse anticipates that this will cause the client's lungs to do what? 1. Improve oxygen uptake 2. Increase carbon dioxide levels 3. Stabilize carbon dioxide levels 4. Reduce the amount of functional alveolar surface area

1. Impaired gas exchange is the priority nursing diagnosis. A client with ARDS usually requires intubation and mechanical ventilation. The other diagnoses are appropriate but not the priority.

A client has developed acute respiratory distress syndrome (ARDS). What is the priority nursing diagnosis for the client? 1. Impaired gas exchange 2. Risk for infection 3. Imbalanced nutrition: Less than body requirements 4. Impaired skin integrity

3. The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventual respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn't manifest these signs.

A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he develops chest tightness, shortness of breath, tachypnea, and decreased level of consciousness. The nurse interprets this assessment data as indicating: 1. asthma attack. 2. pulmonary embolism. 3. respiratory failure. 4. rheumatoid arthritis.

1. Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren't typically associated with smoke inhalation and severe hypoxia.

A firefighter is being treated for smoke inhalation. He develops severe hypoxia 48 hours later, requiring intubation and mechanical ventilation. The nurse determines that the client is experiencing: 1. acute respiratory distress syndrome (ARDS). 2. atelectasis. 3. bronchitis. 4. pneumonia.

4. Blood meets resistance and can't perfuse the pulmonary vasculature because of the embolism. Pulmonary vascular resistance is increased, which reduces the amount of blood returned to the left side of the heart, lowers the cardiac output of the heart, and reduces blood pressure, sometimes significantly.

A client hospitalized with a pulmonary embolism develops hypotension. The nurse determines that the hypotension was the result of which of the following? 1. Pressure on the heart and reduced cardiac output 2. Reduced blood flow to the lung, which causes hypotension 3. Reduced blood return to the right side of the heart leading to lower blood pressure 4. Increased pulmonary vascular resistance and reduced blood delivery to the left side of the heart

1. Immediately after discovering an I.V. infiltration, the nurse should stop the infusion, remove the I.V. catheter, restart the infusion in another site, and apply a warm compress to the infiltrated site. A cool compress doesn't promote fluid absorption. Moist heat shouldn't be applied until the infusion is stopped, the catheter is removed, and another catheter is inserted at a different site. Massaging the site is likely to cause pain and isn't effective in treating an infiltration.

A client is admitted to the hospital with dehydration and pneumonia. Upon admission to the unit, the nurse notes the I.V. has infiltrated. What is the most appropriate action by the nurse? 1. Stop the infusion, remove the I.V. catheter, and restart the infusion in another site. 2. Remove the I.V. catheter and apply a cool compress to the site. 3. Apply moist heat to the site. 4. Gently massage the site.

3. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels.

A client is admitted to the hospital with shortness of breath. The physician orders a stat hemoglobin and hematocrit level to be drawn. The client is questioning why he needs to have blood drawn when he is having trouble breathing. What is the best response by the nurse? 1. "Hemoglobin has no effect on oxygenation." 2. "More hemoglobin reduces the client's respiratory rate." 3. "Low hemoglobin levels cause reduced oxygen-carrying capacity." 4. "Low hemoglobin levels cause increased oxygen-carrying capacity."

4. BiPAP delivers both CPAP and PEEP. It provides the differing pressures throughout the respiratory cycle, attempting to optimize a client's oxygenation and ventilation. It's used in an effort to avoid intubation for mechanical ventilation. Inspiratory and expiratory pressures are set separately to optimize the client's ventilatory status, and the fraction of inspired oxygen is adjusted to optimize oxygenation. The second choice describes only the CPAP component of BiPAP, and the third choice describes the PEEP component.

A client is being treated with bilevel positive airway pressure (BiPAP). The nurse anticipates that the use of BiPAP will: 1. provide 100% oxygen at both inspiration and expiration. 2. provide pressurized oxygen so the client can breathe more easily. 3. provide pressurized oxygen at the end of expiration to open collapsed alveoli. 4. provide both continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) to provide optimal oxygenation and ventilation.

1. Giving oxygen would be the best first action in this case. Vital signs should then be checked and the physician immediately notified. If the client doesn't already have an I.V. catheter, one may be inserted now if anaphylactic shock is developing. Obtaining a CBC wouldn't help the emergency situation.

A client is experiencing an anaphylactic reaction to a drug. What is the most important intervention for the nurse to perform? 1. Administering oxygen 2. Inserting an I.V. catheter 3. Obtaining a complete blood count (CBC) 4. Taking vital signs

1. Inhaled beta-adrenergic agents help promote bronchodilation, which improves oxygenation. I.V. beta-adrenergic agents can be used but have to be monitored because of their greater systemic effects. They're typically used when the inhaled beta-adrenergic agents don't work. Corticosteroids are slowacting, so their use won't reduce hypoxia in the acute phase.

A client is experiencing status asthmaticus. What is the nurse's priority intervention for this client? 1. Inhaled beta-adrenergic agents 2. Inhaled corticosteroids 3. I.V. beta-adrenergic agents 4. Oral corticosteroids

2. Multiple rib fractures and paradoxical chest-wall movement confirm a diagnosis of flail chest. Tension pneumothorax causes severe respiratory distress, hypotension, diminished breath sounds over the affected area, hyperresonance, distended neck veins, eventual tracheal shift, and, possibly, paradoxical chest-wall movement on the injured side. A ruptured diaphragm leads to hyperresonance on percussion, hypotension, dyspnea, dysphagia, and shifting of heart and bowel sounds in the lower to middle chest. A massive hemothorax produces signs of shock (such as tachycardia and hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress, and, possibly, mediastinal shift.

A client is involved in a motor vehicle accident. Upon admission to the emergency department, he has a heart rate of 130 beats/minute, shallow respirations at a rate of 32 breaths/minute, and a blood pressure of 90/60 mm Hg. Breath sounds are diminished on the right side, and paradoxical chest-wall movement appears on the right side. A chest X-ray reveals a right pneumothorax with multiple rib fractures. The nurse anticipates that this client will have a diagnosis of: 1. tension pneumothorax. 2. flail chest. 3. ruptured diaphragm. 4. massive hemothorax.

2. A chest X-ray should be done to ensure and document that the lung is reexpanded and has remained expanded since suction was discontinued. The drainage system shouldn't be disconnected from the tube while still in the client because that could cause a pneumothorax to recur. A pulse oximetry measurement is sufficient to track oxygenation before the tube is removed.Client cooperation is desirable; if the client can hold his breath while the chest tube is removed, there's less chance that air will be drawn back into the pleural space during removal.

A client is scheduled to have a chest tube removed. What is the most important intervention for the nurse to perform prior to the removal? 1. Disconnect the drainage system from the tube. 2. Obtain a chest X-ray to document reexpansion. 3. Obtain an arterial blood gas level to document oxygen status. 4. Sedate the client, and the physician will slip the tube out without warning the client.

3. If the trigger of an acute asthma attack is known, this trigger should be avoided at all times. Using an inhaler before eating wouldn't prevent the attack, and food is commonly a trigger for an acute asthma attack.

A client tells the nurse that he was recently diagnosed with an allergy to Chinese food after he experienced an asthmatic attack. The nurse determines that teaching is successful when the client makes which statement? 1. "I should only eat Chinese food once per month." 2. "I should use my inhalers before eating Chinese food." 3. "I should avoid Chinese food because this is a trigger for me." 4. "I should determine other causes because Chinese food wouldn't cause such a violent reaction."

2. Opioids such as morphine can cause respiratory arrest if given in large quantities. It's unlikely the client will have an asthma attack or a seizure or wake up on his own.

A client was given morphine for pain at 9:00 am. At 9:45 a.m., the nurse assesses the client and notes a respiratory rate of 4 breaths/minute. The nurse recognizes that the client is at highest risk for which of the following? 1. Asthma attack 2. Respiratory arrest 3. Seizure 4. Arousal

1. PEEP can be added to open up alveoli and keep them open. There's no reason to give the client beta-adrenergic blockers. He may benefit from diuresis, but in the meantime, PEEP should be added to improve oxygenation. The highest amount of oxygen that can be delivered is 100% FIO2.

A client who developed a fat embolism is receiving 100% FIO2 on a mechanical ventilator and continues to be hypoxic. What is the most important intervention? 1. Add positive end-expiratory pressure (PEEP). 2. Give beta-adrenergic blockers. 3. Give diuretics. 4. Increase the FIO2 on the ventilator.

1. Warfarin inhibits clot formation by interfering with clotting factors that are dependent on vitamin K. Warfarin doesn't dissolve clots and won't reduce the size of the pulmonary embolus. It doesn't reduce blood pressure and won't prevent venous stasis. Coagulation studies will be performed every 2 to 4 weeks while the client is receiving warfarin.

A client who was hospitalized for pulmonary embolism is being discharged on warfarin (Coumadin) therapy. The client asks the nurse to explain how warfarin works. The best response by the nurse is: 1. "It inhibits the formation of blood clots." 2. "It will reduce the size of the pulmonary embolism." 3. "It will reduce blood pressure and prevent venous stasis." 4. "It will dissolve an existing clot."

2. Neuromuscular blockers cause skeletal muscle paralysis, reducing the amount of oxygen used by the restless skeletal muscles. This should improve oxygenation. Diuretics can be administered to reduce pulmonary congestion, and the head of the bed should be partially elevated to facilitate diaphragm movement. Bronchodilators may be used, but they typically don't have enough of an effect to reduce the amount of hypoxia present. However, diuretics, head elevation, and bronchodilators would improve oxygen delivery, not reduce oxygen demand.

A client with a fat embolism continues to be hypoxic following therapy with positive end-expiratory pressure. What is the priority intervention to reduce oxygen demand? 1. Give diuretics. 2. Give neuromuscular blockers. 3. Put the head of the bed flat. 4. Use bronchodilators.

4. A client with a massive pulmonary embolism will have a large region of lung tissue unavailable for perfusion. This causes the client to hyperventilate and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.

A client with a massive pulmonary embolism is scheduled to have arterial blood gas analysis performed. The nurse expects the analysis will identify: 1. metabolic acidosis. 2. metabolic alkalosis. 3. respiratory acidosis. 4. respiratory alkalosis.

3. The goal of oxygen therapy for a client with a pulmonary embolism is to have a PaO2 greater than 60 mm Hg on an FIO2 of 40% or less. The normal range of the PaCO2 is 35 to 45 mm Hg. In the absence of other pathologic states, it should reach normal levels before the PaO2 does on room air because carbon dioxide crosses the alveolar-capillary membrane with greater ease.

A client with a pulmonary embolism has been placed on oxygen therapy. The nurse is reviewing lab work and determines that the therapy is effective when the lab work shows which value? 1. PaCO2 greater than 40 mm Hg 2. PaCO2 less than 40 mm Hg 3. PaO2 greater than 60 mm Hg 4. PaO2 less than 60 mm Hg

1. Once the pulmonary embolism has been diagnosed and the amount of hypoxia determined, chest pain and the accompanying apprehension can be treated with analgesics as long as respiratory status isn't compromised. Using guided imagery and providing emotional support can be used as alternatives. Positioning the client on his left side when a pulmonary embolism is suspected may prevent a clot that has extended through the capillaries and into the pulmonary veins from breaking off and traveling through the heart into the arterial circulation, leading to a massive stroke.

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the priority intervention by the nurse? 1. Administering analgesics 2. Using guided imagery 3. Positioning the client on his left side 4. Providing emotional support

4. The client with a pulmonary embolism has a portion of the lung not involved in oxygenation, causing the client to feel apprehensive. If the area involved is large, the apprehension can be great, giving the client the feeling of "impending doom." The inflammatory reaction in the lung causes chest pain. There's no actual loss of lung tissue, and chest expansion isn't affected

A client with a pulmonary embolism tells the nurse that he feels a sense of "impending doom." The nurse recognizes that this manifestation is caused by what? 1. Inflammatory reaction in the lung parenchyma 2. Loss of chest expansion 3. Loss of lung tissue 4. Sudden reduction in adequate oxygenation

1, 5, and 6. In addition to pleuritic chest pain and dyspnea, a client with a pulmonary embolus may also present with a low-grade fever, tachycardia, and blood-tinged sputum. Thick green sputum would indicate infection, and frothy sputum would indicate pulmonary edema. A client with a pulmonary embolus is tachycardic (to compensate for decreased oxygen supply), not bradycardic.

A client with a suspected pulmonary embolus is brought to the emergency department complaining of shortness of breath and pleuritic chest pain. Select all of the assessment data that would support this diagnosis. 1. Low-grade fever 2. Thick green sputum 3. Bradycardia 4. Frothy sputum 5. Tachycardia 6. Blood-tinged sputum

2. Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief.

A client with acute asthma is experiencing inspiratory and expiratory wheezes and a decreased forced expiratory volume. What is the priority intervention by the nurse? 1. Beta-adrenergic blockers 2. Bronchodilators 3. Inhaled steroids 4. Oral steroids

3. In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles (short explosive or popping sounds) commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi (low-pitched sounds with a snoring quality) suggest secretions in the large airways. Wheezes (high-pitched, hissing sounds) result from narrowed airways, as in asthma, chronic obstructive pulmonary disease, or bronchitis.

A client with cancer develops pleural effusion. During chest auscultation, what would the nurse expect to hear? 1. Crackles 2. Rhonchi 3. Diminished breath sounds 4. Wheezes

1. Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the respiratory rate. It also may reduce edema and improve mobility a little, but exercise tolerance will still be poor. Sputum may get thicker and make it harder to clear airways. Reducing fluid volume won't improve respiratory function but may improve oxygenation.

A client with chronic obstructive bronchitis asks the nurse why he is receiving diuretic therapy. What is the best response by the nurse? 1. Reducing fluid volume reduces oxygen demand. 2. Reducing fluid volume improves clients' mobility. 3. Reducing fluid volume reduces sputum production. 4. Reducing fluid volume improves respiratory function.

4. A client with COPD should verbalize the need to avoid exposure to powders, dusts, and smoke from cigarettes, pipes, and cigars. He should stay indoors when the humidity, temperature, and pollen counts are high; avoid enclosed, crowded areas during cold and flu season; and avoid aerosol sprays. He should obtain immunizations against pneumococcal pneumonia as well as influenza.

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) presents to the clinic for a routine examination. The nurse teaches him strategies for preventing airway irritation and infection. The nurse determines teaching was successful when the client states: 1. "I should avoid enclosed, crowded areas during the summer." 2. "I'm glad I only need to get the flu vaccine." 3. "I should use products with aerosol sprays." 4. "I should avoid using powders."

3. The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physician's order. Antibiotics may be warranted, but this isn't a nursing decision. The client should be maintained on bed rest if he's dyspneic to minimize his oxygen demands, but providing additional oxygen will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.

A client with pneumonia develops dyspnea, a respiratory rate of 32 breaths/minute, and difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the left lower lobe. Which action should the nurse take first? 1. Administer antibiotics. 2. Encourage bed rest. 3. Apply oxygen. 4. Assess nutritional intake.

1. The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There's a loss of lung parenchyma and subsequent scar tissue formation, but these don't cause hemoptysis.

A client with pulmonary embolism has developed hemoptysis. The nurse determines that this is most likely related to: 1. alveolar damage in the infarcted area. 2. involvement of major blood vessels where the clot formed. 3. loss of lung parenchyma. 4. loss of lung tissue.

4. A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

A client with shortness of breath has decreased-to-absent breath sounds on the right side, from the apex to the base. The nurse interprets this assessment data as indicating which condition? 1. Acute asthma 2. Chronic bronchitis 3. Pneumonia 4. Spontaneous pneumothorax

4. Normal ABG values include a pH of 7.35 to 7.45; PaCO2 of 35 to 45 mm Hg; PaO2 of 75 to 100 mm Hg; and HCO3 − of 22 to 26 mEq/L. This client has a below-normal pH, an elevated PaCO2, and normal HCO3 −, indicating respiratory acidosis. With metabolic acidosis, pH and HCO3 − are low and PaCO2 is normal. In respiratory alkalosis, pH is elevated and PaCO2 is low. In metabolic alkalosis, both pH and HCO3 − are elevated.

A client's arterial blood gas (ABG) analysis reveals a pH of 7.18, PaCO2 of 73 mm Hg, PaO2 of 77 mm Hg, and HCO3 − of 24 mEq/L. The nurse interprets these values as indicating what? 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis

3. Because the PaCO2 is high at 80 mm Hg and the metabolic measure, HCO3 −, is normal, the client has respiratory acidosis. The pH is less than 7.35, acidemic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3 − was below 22 mEq/L, the client would have metabolic acidosis.

A client's arterial blood gas (ABG) results are as follows: pH, 7.16; PaCO2, 80 mm Hg; PaO2, 46 mm Hg; HCO3 −, 24 mEq/L; SaO2, 81%. The nurse would interpret the results as indicating: 1. metabolic acidosis. 2. metabolic alkalosis. 3. respiratory acidosis. 4. respiratory alkalosis.

2. Heparin is started I.V. once a pulmonary embolism is diagnosed to reduce further clot formation. When a therapeutic level of heparin is established, warfarin is started. It can take up to 3 days before a therapeutic level of warfarin is achieved. Streptokinase is a fibrinolytic, and its usefulness in the management of pulmonary embolism is unclear. Acyclovir is an antiviral and is not prescribed after a pulmonary embolism.

A definitive diagnosis of pulmonary embolism has been made for a client. The nurse anticipates which medication will be ordered? 1. Warfarin (Coumadin) 2. Heparin 3. Streptokinase (Streptase) 4. Acyclovir (Zovirax)

3. Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during exhalation. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation and are best heard over the upper third of the sternum and between the scapulae.

A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sounds? 1. Bronchial 2. Tracheal 3. Vesicular 4. Bronchovesicular

3. Because this is an acute episode, listen to the client's lungs to see if anything has changed. Don't give this client medication, especially sedatives, if he's having difficulty breathing. Give the client emotional support and contact the physician who placed the central venous access.

A hospitalized client has a central I.V. catheter inserted in the subclavian vein. Shortly after placement, the client develops shortness of breath and appears restless. The priority action by the nurse would be? 1. Administer a sedative. 2. Advise the client to calm down. 3. Auscultate for breath sounds. 4. Check to see if the client can have medication.

3. The mask provides pressurized oxygen continuously through both inspiration and expiration. The mask can be set to deliver any amount of oxygen needed. By providing a client with pressurized oxygen, the client has less resistance to overcome in taking in his next breath, making it easier to breathe. Pressurized oxygen delivered at the end of expiration is positive endexpiratory pressure, not CPAP.

A hospitalized client is experiencing hypoxia. The physician orders continuous positive airway pressure (CPAP) per face mask. The family is concerned and questions the nurse as to why the client needs the mask. What is the most appropriate response by the nurse? 1. "The mask is providing 100% oxygen to the client." 2. "The mask is providing continuous air that the client can breathe." 3. "The mask is providing pressurized oxygen so the client can breathe more easily." 4. "The mask is providing pressurized oxygen at the end of expiration to open collapsed alveoli."

1. The nurse should open the airway and begin rescue breathing immediately—while still in the water, if possible. Immobilizing the cervical spine won't provide the needed oxygenation. Chest compressions should be delivered only if circulation is absent. Performing abdominal thrust in an attempt to remove water from the lungs would delay the start of rescue breathing.

A nurse attending a neighborhood picnic notices an adult at the bottom of the swimming pool. She immediately calls for help and tries to rescue the person. When she pulls him out, he's unresponsive and breathless. What is the most appropriate action by the nurse? 1. Open the airway and begin rescue breathing immediately. 2. Immobilize the cervical spine. 3. Start chest compressions. 4. Perform abdominal thrust.

The client is to receive the solution at an infusion rate of 125 ml/hour. 125 ml × 8 hours = 1,000 ml, the total volume in milliliters the client will receive during an 8-hour shift. Convert milliliters to liters by dividing by 1,000. The total volume in liters of normal saline solution that the client will receive in 8 hours is 1 L.

A physician prescribes an I.V. solution to infuse at a rate of 125 ml/hour for a client. How many liters of solution will the client receive during an 8-hour shift? Record your answer using a whole number._________________________ liters

3. Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. They don't take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology. If too much oxygen is given, the client has little stimulus to take another breath. In the meantime, his carbon dioxide levels continue to climb, and the client will pass out, leading to respiratory arrest.

A student nurse is asking the staff nurse why a client with emphysema should receive only 1 to 3 L/minute of oxygen, if needed. The nurse determines that teaching was effective when the student makes which statement? 1. "The client doesn't notice he needs to breathe." 2. "The client breathes only when his oxygen levels climb above a certain point." 3. "The client breathes only when his oxygen levels dip below a certain point." 4. "The client breathes only when his carbon dioxide level dips below a certain point."

4. Because of the traumatic cause of injury, the client had a hemothorax, in which blood collection causes the collapse of the lung. The placement of the chest tube will drain the blood from the space and reexpand the lung. There's a very slight chance of nicking an intercostal artery during insertion, but it's fairly unlikely if the person placing the chest tube has been trained. The initial chest X-ray would help confirm whether there was blood in the pleural space or just air.

After a motor vehicle collision, a client has a chest tube inserted in the left upper chest. The tube begins to drain a large amount of dark red fluid. The nurse determines that: 1. the chest tube was inserted improperly. 2. this is an expected result. 3. an artery was nicked when the chest tube was placed. 4. the client is experiencing a hemothorax.

2. These ABG values reveal respiratory alkalosis (elevated pH, decreased PaCO2, and normal PaO2 and HCO3 − levels), so the client is most likely hyperventilating from anxiety. Breathing into a paper bag can stop the hyperventilation by increasing carbon dioxide. Doing nothing or giving sodium bicarbonate could worsen respiratory alkalosis. The client has a normal PaO2 level and doesn't need supplemental oxygen.

After experiencing an anxiety attack, a client comes to the emergency department complaining of dizziness and light-headedness. Arterial blood gas (ABG) analysis reveals a pH of 7.62, PaCO2 of 22 mm Hg, PaO2 of 96 mm Hg, and HCO3 − of 24 mEq/L. What is the most appropriate action by the nurse? 1. Do nothing; these ABG values are normal. 2. Encourage the client to breathe into a paper bag. 3. Notify the physician and prepare to give sodium bicarbonate. 4. Notify the physician and prepare to give supplemental oxygen.

1. Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space. Bubbling doesn't normally occur with either adequate or inadequate suction. A kinked chest tube can stop the suction and any preexisting bubbling in the water seal chamber.

An 18-year-old client who was involved in a motor vehicle accident is admitted to the hospital with a diagnosis of pneumothorax. A chest tube was inserted and attached to a chest drainage system. The nurse notes bubbling in the water seal chamber and determines further assessment is required. The nurse is aware the bubbling is most likely the result of: 1. air leaks. 2. adequate suction. 3. inadequate suction. 4. kinked chest tubes.

1. The client should verbalize the need to use the inhaler no more than 1 hour before exercise when indicated for exercise-induced asthma. Cromolyn is contraindicated during an acute asthma attack. A client who is taking steroids should continue to take them during cromolyn therapy, if appropriate. Gargling and rinsing the mouth after cromolyn administration can reduce mouth dryness.

An asthmatic client is being discharged with a prescription for cromolyn (Intal inhaler). The nurse determines teaching was effective when the client makes which statement? 1. "I should use my inhaler no more than 1 hour before I exercise." 2. "I should use my inhaler whenever I feel an asthma attack coming on." 3. "I should stop taking steroids if I need a dose of my inhaler." 4. "I should avoid gargling and rinsing my mouth after using my inhaler."

2. This client needs information about the dangers of taking pills and alcohol together. It may not be advisable to feed the client at first in case his level of consciousness decreases again, increasing the possibility of aspiration. Discharge at this point is inappropriate. Unless the client was trying to commit suicide, admission to a psychiatric facility isn't necessary.

An unconscious client who overdosed on an opioid while consuming alcohol receives naloxone (Narcan). After he awakens, what is the most important action for the nurse to perform? 1. Feed the client. 2. Teach the client about the effects of taking pills and alcohol together. 3. Discharge the client from the hospital. 4. Admit the client to a psychiatric facility.

1. Nursing management of a client with a pulmonary embolism focuses on assessing oxygenation status and ensuring that treatment is adequate. If the client's status begins to deteriorate, it's the nurse's responsibility to contact the physician and attempt to improve oxygenation. Ensuring that the oxygen delivery device is working properly and monitoring for other clot sources are other nursing responsibilities, but they aren't the focus of care. The physician would determine if the client required another (V/Q) scan.

Nursing management of a client with a pulmonary embolism will primarily focus on which action? 1. Assessing oxygenation status 2. Monitoring the oxygen delivery device 3. Monitoring for other sources of clots 4. Determining whether the client requires another ventilation-perfusion (V/Q) scan

2. Thoracentesis is used to remove excess pleural fluid and restore proper lung status. The fluid is then analyzed to determine if it's transudative or exudative. Transudates are substances that have passed through a membrane and usually occur in low protein states. Exudates are substances that have escaped from blood vessels. They contain an accumulation of cells and have a high specific gravity and a high lactate dehydrogenase level. Exudates usually occur in response to a malignancy, infection, or inflammatory process. A chest tube is rarely necessary because the amount of fluid typically isn't large enough to warrant such a measure. Paracentesis is the removal of fluid from the abdomen. Pleural effusions can't drain by themselves.

The client has developed a pleural effusion. The nurse anticipates that the most appropriate intervention would be? 1. Inserting a chest tube 2. Performing thoracentesis 3. Performing paracentesis 4. Allowing the pleural effusion to drain by itself

4. PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart, thereby reducing cardiac output. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing a compensatory tachycardia.

The client is receiving positive end-expiratory pressure (PEEP) therapy. The nurse anticipates that the client will exhibit which of the following? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Reduced cardiac output

3. A chest X-ray will show the area of collapsed lung if a pneumothorax is present as well as the volume of air in the pleural space. Listening to breath sounds won't confirm a diagnosis. An incentive spirometer is used to encourage deep breathing. A needle thoracostomy is done only in an emergency and only by someone trained to do it.

The client is suspected of having a pneumothorax. The nurse anticipates the diagnosis will be confirmed by: 1. auscultating breath sounds. 2. having the client use an incentive spirometer. 3. chest X-ray. 4. thoracic puncture.

4. A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.

The nurse assesses a client who has been given an opioid analgesic and determines that the client is at risk for developing respiratory arrest. An arterial blood gas (ABG) is obtained. The nurse reviews blood gas results and determines which PaCO2 value places the client at highest risk? 1. 15 mm Hg 2. 30 mm Hg 3. 40 mm Hg 4. 80 mm Hg

3. Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds, and, at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Clients with asthma don't exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.

The nurse hears a physician refer to a client as a "blue bloater." The nurse is aware that this term refers to: 1. acute respiratory distress syndrome (ARDS). 2. asthma. 3. chronic obstructive bronchitis. 4. emphysema.

4. In emphysema, the wall integrity of the individual air sacs is damaged, reducing the surface area available for gas exchange. Very little air movement occurs in the lungs because of bronchiole collapse as well. In ARDS, the client's condition is more acute and typically requires mechanical ventilation. In asthma and bronchitis, wheezing is prevalent.

The nurse is assessing a 69-year-old client who appears thin and cachectic. The client is short of breath at rest, dyspneic with the slightest exertion, and has diminished breath sounds with deep inspiration. The nurse interprets these assessment findings as indicative of: 1. acute respiratory distress syndrome (ARDS). 2. asthma. 3. chronic obstructive bronchitis. 4. emphysema.

3. If the chest tube is inserted correctly, normal bronchovesicular breath sounds in that area will be heard and the client's oxygenation status will improve. A chest X-ray should be done to ensure reexpansion. All other sounds noted are abnormal.

The nurse is auscultating the lungs of a client following chest tube insertion. What assessment finding would indicate to the nurse correct chest tube placement? 1. Bronchial sounds heard at both bases 2. Vesicular sounds heard over upper lung fields 3. Bronchovesicular sounds heard over both lung fields 4. Crackles heard on the affected side

2. The client with massive trauma will require multiple transfusions. Blood products are preserved with citrate, which causes increased permeability in the lungs, the defect that allows ARDS to develop. Appendicitis, unless it causes overwhelming sepsis, won't lead to ARDS. Conscious sedation and injuries to the meniscus don't lead to ARDS.

The nurse is aware that which diagnosis is most likely to contribute to the development of acute respiratory distress syndrome (ARDS)? 1. Appendicitis 2. Massive trauma 3. Receiving conscious sedation 4. Right meniscus injury

1. Atelectasis develops when there's interference with the normal negative pressure that promotes lung expansion. Clients in the postoperative phase oftensplint their breathing because of pain and positioning, which causes hypoxia. It's uncommon for any of the other respiratory disorders to develop.

The nurse is caring for a client in the immediate postoperative period. The priority of care would include interventions to prevent: 1. atelectasis. 2. bronchitis. 3. pneumonia. 4. pneumothorax.

4. Using an incentive spirometer requires the client to take deep breaths and promotes lung expansion. Chest physiotherapy helps mobilize secretions but won't prevent atelectasis. Reducing oxygen requirements or placing someone on mechanical ventilation doesn't affect the development of atelectasis.

The nurse is preparing a plan of care for a postoperative client. What is the most appropriate nursing intervention to prevent the development of atelectasis? 1. Chest physiotherapy 2. Mechanical ventilation 3. Reducing oxygen requirements 4. Use of an incentive spirometer

4. One indication of reexpansion is the cessation of fluctuation in the water seal chamber when suction isn't applied. Drainage should be minimal before the chest tube is removed. An ABG analysis may be done to ensure proper oxygenation but isn't necessary if clinical assessment criteria are met. The chest tube isn't removed until it's determined the client's lung has adequately reexpanded and will stay that way. After the lung stays expanded, the chest tube is removed.

The nurse is caring for a client who had a chest tube inserted for treatment of a pneumothorax. Which assessment finding best indicates to the nurse that a chest tube is no longer needed? 1. The drainage from the chest tube is minimal. 2. Arterial blood gas (ABG) levels are obtained to ensure proper oxygenation. 3. It's removed and the client is assessed to see if he's breathing adequately. 4. No fluctuation in the water seal chamber occurs when no suction is applied.

1. Inserting an I.V. catheter in the subclavian vein can result in a pneumothorax, so a chest X-ray should be done. If it's negative, then other tests should be done, but they aren't appropriate as the first intervention. Sedation may depress respirations.

The nurse is caring for a client who recently had a central venous catheter inserted and now appears short of breath and anxious. The nurse anticipates that the physician will order a: 1. chest X-ray. 2. electrocardiogram. 3. laboratory tests. 4. sedation.

4. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion. The collapse of alveoli or a bronchiole has no particular name. Fluid within the alveolar space can be caused by heart failure or adult respiratory distress syndrome.

The nurse is caring for a client with a pleural effusion. The client asks, "What is a pleural effusion?" What is the most appropriate response from the nurse? 1. "It is the collapse of alveoli." 2. "It is the collapse of a bronchiole." 3. "It is the fluid in the alveolar space." 4. "It is the accumulation of fluid between the linings of the pleural space."

4. Venous thrombi in the thigh and pelvis are the most common sources for pulmonary emboli. Clients who are immobile form clots from this source. When dislodged, the clots are carried through the bloodstream and lodge in the pulmonary vasculature. The other options are also sources but not the most common.

The nurse is conducting a preoperative class for clients scheduled for gastric bypass surgery. One of the clients asks the nurse what the most common source of pulmonary embolism is. The most appropriate response by the nurse is: 1. amniotic fluid. 2. bone marrow. 3. septic thrombi. 4. venous thrombi.

1. Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia better, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients can't tolerate the type of exercise necessary to do this. Exercise won't reduce the number of acute attacks. In some instances, exercise may be contraindicated, and the client should check with his physician before starting any exercise program.

The nurse is conducting a weekly support group for clients diagnosed with asthma, chronic bronchitis, and emphysema. The topic of today's class is exercise. The nurse determines teaching is effective when the clients states that exercise: 1. enhances cardiovascular fitness. 2. improves respiratory muscle strength. 3. reduces the number of acute attacks. 4. worsens respiratory function and is discouraged

3. In ARDS, the alveolar membranes are more permeable and the spaces are fluid filled. Alveoli collapse, impairing gas exchange. The fluid interferes with gas exchange and reduces perfusion.

The nurse is explaining the process of acute respiratory distress syndrome (ARDS) to a client. What is the best explanation for the nurse to tell the client? 1. Alveoli are overexpanded. 2. Alveoli increase perfusion. 3. Alveolar spaces are filled with fluid. 4. Alveoli improve gaseous exchange.

3. Pulse oximetry determines the percentage of hemoglobin carrying oxygen. This doesn't ensure that the oxygen being carried through the bloodstream is actually being taken up by the tissue. Pulse oximetry doesn't provide information about the amount of carbon dioxide or oxygen in the blood or the client's respiratory rate.

The nurse is obtaining a pulse oximetry reading on a client. The nurse is aware that analysis of the results will provide information regarding: 1. amount of carbon dioxide in the blood. 2. amount of oxygen in the blood. 3. percentage of hemoglobin carrying oxygen. 4. respiratory rate.

3. Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be "tight" sounding or markedly decreased; they won't be normal.

The nurse is performing an assessment on a client with a suspected diagnosis of asthma. Which assessment finding supports the diagnosis? 1. Circumoral cyanosis 2. Increased forced expiratory volume 3. Inspiratory and expiratory wheezing 4. Normal breath sounds

1. Early ambulation helps reduce pooling of blood, which reduces the tendency of the blood to form a clot that could then dislodge. Frequent chest Xrays or lower extremity scans don't prevent pulmonary embolism. Intubation of the client won't prevent the occurrence of a pulmonary embolism.

The nurse is planning care for a client who has undergone a total knee replacement. The most important intervention to prevent the development of a pulmonary embolism would be? 1. Early ambulation 2. Frequent chest X-rays to find a pulmonary embolism 3. Frequent lower extremity scans 4. Intubation of the client

2. The nurse must anticipate that a drainage system is required and set this up before insertion so the tube can be directly connected to the drainage system. The chest X-ray need not be brought to the client's room. A physician will insert the chest tube.

The nurse is preparing a client to have a chest tube inserted in the right upper chest. What is the priority role of the nurse? 1. The nurse isn't needed. 2. Preparing the chest tube drainage system 3. Bringing the chest X-ray to the client's room 4. Inserting the chest tube

1. First, perform Allen's test to assess circulation. Next, wash your hands, put on gloves, and place a rolled towel under the client's wrist for support. Then locate the artery and palpate it for a strong pulse. Next, clean the puncture site with an alcohol or povidone-iodine pad. Then palpate the artery with the index and middle fingers of one hand while holding the syringe over the puncture site with the other hand. Holding the needle bevel at a 30- to 45- degree angle, puncture the skin and arterial wall in one smooth motion, watch for blood backflow in the syringe, and fill it to the 5-ml mark. After collecting the sample, press a gauze pad over the puncture site for at least 5 minutes.

The nurse is preparing to obtain an arterial blood gas (ABG) sample on a client. Which action should the nurse take first? 1. Perform Allen's test. 2. Place a rolled towel under the client's wrist. 3. Clean the puncture site with an alcohol or povidone-iodine pad. 4. Palpate the artery with the index and middle fingers of one hand.

4. If the pulmonary embolism is large and doesn't respond to treatment, surgical removal may be necessary to restore perfusion to the area of the lung. This is rarely done because of the associated high mortality risk. It's impossible to remove a pulmonary embolism through bronchoscopy because the defect isn't in the bronchial tree. A thrombectomy can be performed at other sources of clot, but when a pulmonary embolism has already occurred, it would have little effect on oxygenation.

The nurse is providing preoperative teaching for a client with a pulmonary embolism scheduled for an embolectomy. The most appropriate information for the nurse to give the patient is: 1. "It is done to remove an embolism in the lower extremity." 2. "It sucks an embolism out of the lung by bronchoscopy." 3. "It surgically removes the embolism source in the pelvis." 4. "It surgically removes the embolism in the pulmonary vasculature."

4. Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs. Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, although by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.

The nurse is reviewing a client's chest X-ray report that states that there are bilateral areas of collapsed alveoli in the bases. The nurse initiated coughing and deep breathing exercises, reinforced the use of the incentive spirometer, and encouraged the client to ambulate in the halls at least twice a day. The nurse implemented these interventions into the plan of care based on what knowledge? 1. Alveoli need oxygen to live. 2. Alveoli have no effect on oxygenation. 3. Collapsed alveoli increase oxygen demand. 4. Gaseous exchange occurs in the alveolar membrane.

3. Heparin slows the development of other clots. It doesn't break up pulmonary embolisms or dissolve clots already formed. Heparin doesn't stop clots from going to the lung.

The nurse is teaching a client diagnosed with a pulmonary embolism about the prescribed heparin therapy. The nurse determines that teaching has been effective when the client states heparin is given to: 1. dissolve the clot. 2. break up the pulmonary embolism. 3. slow the development of other clots. 4. prevent clots from breaking off and embolizing to the lung.

1. A pulmonary embolism blocks the flow of blood past a region of the lung tissue, which is still being ventilated because no disorder of the bronchial tree exists. A pulmonary embolism blocks the pulmonary vasculature, not allowing blood to flow to the distal region of the lung and interfering with gas exchange. Blood must flow around each alveolus, or perfuse, for the exchange of carbon dioxide and oxygen to occur across the alveolar-capillary membrane. When an area of lung is ventilated but not perfused, there is a ventilation-perfusion mismatch specific to pulmonary embolism. A mismatch that shows impaired ventilation but normal perfusion indicates a pathological state in the bronchial tree, such as pneumonia or atelectasis.

The nurse is teaching the client about his diagnosis of a pulmonary embolism. The client tells the nurse that the doctor told him that he has a ventilation-perfusion mismatch. Which statement by the client best conveys an understanding of the diagnosis? 1. The area of the lung being ventilated isn't being perfused. 2. The area of the lung being perfused isn't being ventilated. 3. The area of the lung being ventilated is also being perfused. 4. The amount of ventilation occurring doesn't equal perfusion.

2. To prevent hypoxia, continuous suctioning shouldn't last more than 10 seconds at a time during catheter withdrawal. Suction shouldn't be applied while the catheter is being advanced.

The nurse is teaching the family of an older adult client who requires long-term ventilator therapy how to suction the client. The client has a tracheostomy in place and requires frequent suctioning. The nurse determines teaching was effective when the family is observed: 1. using intermittent suction while advancing the catheter. 2. using continuous suction for no longer than 10 seconds while withdrawing the catheter. 3. using continuous suction for no longer than 20 seconds while withdrawing the catheter. 4. using continuous suction while advancing the catheter.

1. When the suction source is turned off, the drainage system should be opened to the atmosphere so intrapleural air can escape from the system. Detaching the tubing from the suction port provides an exit vent for the air and, thus, reduces the risk of tension pneumothorax. Clamping the tube may cause air to accumulate in the pleural space, rapidly leading to tension pneumothorax. There's no need to question the order.

The nurse notes an order to change the client's chest drainage system from suction to gravity drainage. What is the most appropriate action by the nurse? 1. Detach the tubing from the suction port to provide a vent. 2. Clamp the client's drainage tube. 3. Question the physician's order. 4. Turn off the suction source and leave the tubing connected.

4. A supine position may reduce the ability of posterior alveoli to open and remain open. Turning the client to the prone position may recruit new alveoli in the posterior region of the lung and improve oxygenation status. Cardiac output shouldn't be affected by the prone position. The prone position doesn't make the client more comfortable, and he often requires sedation to tolerate it. Skin breakdown can still occur over the new pressure points.

The nurse placed a client diagnosed with acute respiratory distress syndrome in the prone position. The nurse determined that this positioning of the client would: 1. improve cardiac output. 2. make the client more comfortable. 3. prevent skin breakdown. 4. recruit more alveoli.

1. Improved ABG results would indicate that the client's oxygenation status is improved. Hypoxia is the problem in ARDS, so bronchoscopy and sputum culture results may have no bearing on the improvement of ARDS. Increased blood pressure isn't relative to the client's respiratory condition.

The nurse reviews the assessment of a client with acute respiratory distress syndrome (ARDS). What is the best indicator of improvement in the client? 1. Arterial blood gas (ABG) values 2. Bronchoscopy results 3. Increased blood pressure 4. Sputum culture and sensitivity results

4. Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They're pink and usually breathe through pursed lips, hence the term "puffer." Clients with ARDS are usually acutely short of breath. Clients with asthma don't have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

The nurse views the term "pink puffer" on a client's chart. This assessment finding leads the nurse to suspect that the client may be experiencing: 1. acute respiratory distress syndrome (ARDS). 2. asthma. 3. chronic obstructive bronchitis. 4. emphysema.

2. If the client took opioids, giving naloxone could reverse the effects and awaken the client. I.V. fluids will most likely be administered, and he'll be closely monitored over a period of several hours to several days. A drug screen should be drawn, but results may not come back for several hours.

The nurse's initial assessment of the client is indicative of probable opioid overdose complicated by alcohol ingestion. What is the most important intervention for the nurse to perform? 1. Administer I.V. fluids. 2. Administer I.V. naloxone (Narcan). 3. Continue close monitoring of vital signs. 4. Draw blood for a drug screen.

1. Pulmonary embolus occurs when a thrombus lodges in a branch of the pulmonary artery, partially or totally occluding it. The lung is adequately ventilated but can't be perfused, resulting in ineffective peripheral tissue perfusion. Although impaired physical mobility is an appropriate nursing diagnosis for this client, it doesn't take priority over ineffective peripheral tissue perfusion. A pulmonary embolus doesn't increase secretions, so ineffective airway clearance isn't an appropriate diagnosis. It also doesn't place the client at risk for aspiration.

Three days after an abdominal aortic aneurysm repair, a client develops a pulmonary embolus. What is the priority nursing diagnosis? 1. Ineffective peripheral tissue perfusion 2. Impaired physical mobility 3. Ineffective airway clearance 4. Risk for aspiration

4. Respiratory infection in clients with a respiratory disorder can be fatal. It's important that the client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate to teach a client how to listen to his own lungs or change his oxygen therapy regimen. If the client has signs and symptoms of an infection, he should contact his physician at once.

What is the most important information for a nurse to teach a client with chronic obstructive pulmonary disease? 1. How to assess his own pulse and respiratory rates 2. How to recognize when a change is needed in his oxygen therapy 3. How to treat respiratory infections without use of antibiotics 4. How to recognize the signs of an impending respiratory infection

4. Thrombosis formation is caused by abnormalities in blood flow, vein wall integrity, and blood coagulation. The client with pelvic and femur fractures will be immobilized and probably have edema, which leads to venous stasis and predisposes him to the development of deep vein thrombosis. A pulmonary embolus commonly arises from clots in the deep veins of the leg that break off and travel to the pulmonary arteries. The risk of developing venous thrombosis isn't as high with the other conditions.

Which client is at highest risk for developing a pulmonary embolism? 1. An ambulatory client with an inflammatory joint disease 2. An ambulatory client who has type 1 diabetes 3. A healthy client who's 6 months pregnant 4. A client who has fractures of his pelvis and right femur

4. The blood clot blocks blood flow to a region of the lung tissue. That area remains ventilated, but because blood flow is blocked, no gas exchange can occur in that region and a ventilation-perfusion mismatch is present. Ventilation isn't initially affected by a blood clot because air can still move normally through the bronchial tree.

Which physiologic effect of a pulmonary embolism would initially affect oxygenation? 1. A blood clot blocks ventilation; perfusion is unaffected. 2. A blood clot blocks ventilation, producing hypoxia despite normal perfusion. 3. A blood clot blocks perfusion and ventilation, producing profound hypoxia. 4. A blood clot blocks perfusion, producing hypoxia despite normal or supernormal ventilation.

1. Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are used to reduce bronchospasm, improve oxygenation, and avoid intubation. Determining the trigger for the client's attack and improving exercise tolerance are later goals. Typically, secretions aren't a problem in status asthmaticus.

Which treatment goal is the nurse's highest priority for a client with status asthmaticus? 1. Avoiding intubation 2. Determining the cause of the attack 3. Improving exercise tolerance 4. Reducing secretions