PassPoint Respiratory Disorders - ML7 Week 2

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A client is experiencing an acute asthmatic attack. Prior to treatment with levalbuterol, respirations were 40 breaths/min, pulse 132 beats/min, oxygen saturation 86% on room air, and there was audible wheezing. Which finding indicates achievement of the desired outcome of asthma treatment?

pulse 96 bpm and SpO2 92% on room air Quick-acting bronchodilators are used in acute asthma to improve airflow and relieve symptoms; following treatment, tachycardia resolves as gas exchange and work of breathing are improved. SpO2 and PEF rates improve, and wheezing from a constricted airway resolves. The normal inspiratory to expiratory ratio is 1:2.

Which measure should the nurse perform when suctioning a tracheostomy tube?

Administer high concentrations of oxygen before suctioning the client. Clients are hyperoxygenated before suctioning to prevent hypoxia.Suction is never applied while inserting the catheter into the airway.Laryngectomy tubes are not changed after suctioning.The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure.

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer

vitamin K1 (phytonadione). Vitamin K1 is the antidote for a warfarin overdose. Heparin is a parenteral anticoagulant. Vitamin C isn't an antidote. Protamine sulfate is the antidote for heparin.

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs?

"Take the albuterol first and follow with beclomethasone two times a day." The nurse instructs the client to administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue, which follows after 1 minute between puffs. Using a spacer device with an MDI provides the best delivery of medication to the lungs.

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day." The nurse should instruct the client to weigh themselves daily and report a gain of 2 lb (0.91 kg) in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all.

A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 ml. How many milliliters of medication would the nurse pour to administer the correct dose? Record your answer as a whole number.

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A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Impaired gas exchange Impaired gas exchange should be the nurse's first priority because of the lack of ventilation due to the surgical procedure and pain. The other options as not first priorities.

Which would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?

Obtain influenza and pneumococcal vaccines. Influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia. Decreasing protein in the diet is not indicated in the prevention of pneumonia and may cause the client to have an inadequate dietary intake of protein. Antibiotics are ineffective against viral infections. Prophylactic antibiotic therapy is not typically prescribed because of the increasing prevalence of resistant bacterial strains.

If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first?

Reposition the airway. If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. A bag-mask device allows for delivery of 100% oxygen, but is difficult to manage if there is just one rescuer; ideally two persons are used to operate the bag-mask device, one to maintain the seal and the other to provide the ventilations. Compressions should be maintained at 100 per minute.

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

Take ordered medications as scheduled. Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks.

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise?

better elimination of carbon dioxide Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

Which task may be safely delegated to a licensed practical nurse (LPN)?

changing the dressing of a client who underwent surgery 2 days ago The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.

A client with emphysema is at a greater risk for developing what acid-base imbalance?

chronic respiratory acidosis Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

depriving the client of sufficient oxygen supply. After suctioning, the client should rest at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac arrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings.The nurse should not prevent stimulating the cough reflex as it helps mobilize secretions.Intermittent suction does not prevent dislodgment of the tracheostomy tube.Intermittent suction does not keep the suction catheter from becoming obstructed; clearing the catheter with normal saline will keep the catheter clear.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? Steroids will:

have an anti-inflammatory effect. Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

measles Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?

oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).

A client has had a central venous pressure line inserted. The nurse should immediately report which sign to the health care provider?

sharp pain on the affected side Sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness indicate a pneumothorax, which can be a complication of inserting a central venous pressure line. The other findings are within normal limits.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

the client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

the client with stridor who just received the first dose of an antibiotic The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. This may indicate an anaphylactic reaction to the antibiotic. The nurse must intervene to prevent anaphylactic shock. The airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the clients with improving chest pain and elevated blood pressure should be assessed.

A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client?

using a cooling mist humidifier and administering dextromethorphan Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say

"I should become involved in a weight loss program." Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:

"I'll stop being contagious when I have a negative acid-fast bacilli test." A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test result for several days. The client will not have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication." The client requires additional teaching if he states that coworkers will need to take medication. If exposed and testing positive, medications would be required for coworkers. Contacts need to be tested for tuberculosis. However, a person in close contact with a person who's infectious is at greatest risk and should be definitely be checked. The client demonstrates effective teaching when stating a need to take medications for 9 to 12 months and that required laboratory tests while on medication.

The nurse is caring for a client with emphysema. The client asks about the reason for persistent respiratory acidosis. What is the best response by the nurse?

"Your alveoli have lost elasticity, which causes retained carbon dioxide." Emphysema causes a loss of alveolar elasticity. The alveoli become hyperinflated with retained carbon dioxide, which leads to chronic respiratory acidosis. While the client with emphysema will experience increased work of breathing, it is the retained carbon dioxide that causes the respiratory acidosis. Narrowed bronchioles and increased mucus production are characteristic of chronic bronchitis, which causes hypoxemia, not respiratory acidosis.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse-manager would take which step to meet the needs of the staff?

Contact the institutional ethics committee for strategies. The institutional ethics committee can help the staff develop strategies to resolve their ethical dilemma. The Patient's Bill of Rights states that the client (not the family) has the right to make decisions about the care plan and to refuse recommended treatment. Arranging a meeting with the client's family is inappropriate, whether or not they are in agreement with the client's wishes. Assigning only nurses that agree with the client's wishes is not a reasonable staffing option. Talking to the client about their concerns is inappropriate as it takes the focus away from the client.

Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)? Select all that apply.

High humidity increases the effort of breathing. A bronchodilator with meter-dose inhaler should be readily available. Smoking cessation is important to slow or stop disease progression. High humidity has been shown to increase the work of breathing. Carrying a metered-dose inhaler can facilitate early intervention if bronchospasm and shortness of breath should occur. Smoking cessation is difficult to achieve but very important in preventing COPD progression. Pulmonary rehabilitation programs are a great source of support for health promotion and maintenance for clients with COPD. Both the pneumococcal and influenza vaccines can help protect again respiratory infections.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be

Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

The nurse is caring for a client with cystic fibrosis (CF) who has increased dyspnea. Which intervention should the nurse include in the plan of care?

Perform chest physiotherapy. Airway clearance techniques are treatments that help people with cystic fibrosis (CF) stay healthy and breathe easier. ACTs loosen thick, sticky lung mucus so it can be cleared by coughing. Clearing the airways reduces lung infections and improves lung function. Routine scheduling of airway clearance using chest physiotherapy is an essential intervention for clients with CF. Fluid restrictions will worsen the thickening of secretions and suctioning the upper airway will not reach thick secretions in the lower lungs. A sweat chloride test is used to diagnose CF; it is not a treatment.

The nurse is offering further education to a client about the management of COPD. Which outcomes would indicate the teaching has been effective? Select all that apply

The client demonstrates pursed-lip breathing and coughing exercises. The client maintains smoking cessation. The client schedules follow-up physician appointments. Demonstration of pursed-lip breathing and coughing exercises by the client is a positive outcome that teaching has been understood. Maintaining smoking cessation as well as follow-up appointments also indicate that teaching has been effective. Exercising for 2 hours a day and continuing to smoke four cigarettes a day are not positive outcomes.

What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion?

Use a sterile catheter each time the client is suctioned. The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.

A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which action is the nurse's most appropriate action?

preparing the client for a chest tube insertion The client's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube. The other options would not be appropriate actions.

A nurse is caring for a client with tuberculosis. Which infection-control technique is the prioritywhen caring for this client?

wearing an N95 respirator when caring for the client Because tuberculosis is transmitted via airborne droplets, the priority for nurses caring for this client is to wear an N95 respirator whenever entering the client's room. Performing hand hygiene before entering the room will not prevent the transmission of TB. When using a fit-tested N95 respirator, it is not necessary to limit the time spent with the client. Isolation gowns are not necessary for airborne isolation.

A client has had surgery for a deviated nasal septum. The client has returned from the postanesthesia care unit. What should the nurse do first?

Assess respiratory status. Immediately after nasal surgery, ineffective breathing patterns may develop as a result of the nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing for airway obstruction is a priority. Assessing for pain is important, but it is not as high a priority as assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not typically a priority nursing assessment after nasal surgery.

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?

returning bicarbonate to the body's circulation The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.

A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis?

risk for activity intolerance These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

using strict hand hygiene The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect

a drop in the client's heart rate. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH?

increased respiratory rate The critically ill client with sepsis is at risk for decreased perfusion of tissues and organs, which leads to lactic acid production. This causes the client to experience metabolic acidosis. To correct the acidosis, the lungs eliminate carbonic acid by blowing off more CO2 via an increased respiratory rate. It is the respiratory system that compensates for metabolic acidosis, not the renal system. Blood pressure will be low in the client with sepsis, but blood pressure is not a compensatory mechanism for pH imbalances. While body temperature can affect acid base balance, this is not how the body compensates for metabolic acidosis.

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care?

increasing the need for antianxiety agents The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care.

A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)?

placing the client on NPO status It would be appropriate for the nurse to instruct the UAP to place the client on NPO status.It is the responsibility of the health care provider performing the procedure to obtain the client's informed consent and have the form signed.It is the responsibility of the registered nurse to teach clients and evaluate their health status. These responsibilities cannot be delegated to a UAP.

What is the rationale that supports multidrug treatment for clients with tuberculosis?

Multiple drugs reduce development of resistant strains of the bacteria. Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (e.g., antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs.

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?

breath sounds clear on auscultation Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning.Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions.Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning.Suctioning clears mucus but does not decrease its production.

A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that they don't want to be resuscitated. The nurse should

check the client's oxygen saturation. The nurse should check the client's oxygen saturation before calling the physician. The fact that the client has signed an advance directive doesn't mean that the nurse shouldn't provide any care. There's no reason for the nurse to get the crash cart at this point.

A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds. The nurse should collaborate with the social worker about the client's financial concerns. This collaboration can be done independently without a physician's order. The physician must notify the public health department of the client's diagnosis, but a public health worker does not get involved with the client's financial concerns. The physician and home health nurse are not typically involved with the client's financial concerns until after the client is discharged.

A nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the

contralateral side in a hemothorax. The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea won't shift. Tracheal deviation toward the contralateral side occurs in simple pneumothorax when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

For a client with a sucking stab wound in the chest wall, the nurse should first:

cover the wound with a petroleum-impregnated dressing. The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound.The nurse can next notify the health care provider. Starting oxygen therapy and preparing for endotracheal intubation may be necessary later, but neither has the same priority on admission as closing the wound.

A client who has been recently extubated has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP?

hemoglobin and hematocrit The nurse should review the CBC with differential to evaluate the client's hemoglobin and hematocrit, which are abnormal and should be reported to the HCP. Anemia leads to decreased oxygen-carrying capacity of the blood. A client unable to compensate for the anemia may experience a profound sense of dyspnea. There has been a significant drop in the hemoglobin and hematocrit since the previous report, and these should be reported to the HCP. The monocytes are within normal range. HA1c is a laboratory test evaluating glycosylated hemoglobin and is in the normal range. This test is used to diagnose diabetes and/or monitor diabetic glucose control over time. PT is a coagulation study reflecting liver function and clotting time and is in the normal range.

When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings?

increased anteroposterior chest diameter Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

Which of the following clients should the nurse assess first?

the client who is a child with stridor and nasal flaring Although all the clients need to be assessed, the highest priority is to evaluate the child with stridor, which indicates impending airway obstruction. Nasal flaring indicates the child is struggling to breathe, a further indication of the critical nature of the situation. The client with wheezing throughout the lung fields would be the second client that needs to be seen. The client in a tripod position could be having increased difficulty breathing or be fatigued and would need to be assessed next. The client with rhonchi would be the lowest priority.

A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take?

Use a sterile suction kit to suction the client. The priority for this client is suctioning to remove secretions in the upper airway if the client is unable to cough adequately. The other interventions will not effectively assist the client to maintain a patent airway.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important?

monitoring intake and output Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

A client is receiving streptomycin to treat tuberculosis. What should the nurse evaluate to determine an adverse effect of the drug?

hearing loss Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection.