practice respiratory questions

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which client statement indicates that further instruction is needed? 1. "I will lie on the affected side for an hour." 2. "I can expect a chest x-ray exam to be done shortly." 3. "I will let you know at once if I have trouble breathing." 4. "I will notify you if I feel a crackling sensation in my chest."

1. "I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the health care provider. A chest x-ray may be performed to evaluate the degree of lung re-expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea Page 559 and 560

A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply. 1. Clamp 2. Code cart 3. Central line kit 4. Vaseline gauze 5. Tracheotomy set 6. Suction equipment

1. Clamp 4. Vaseline gauze 6. Suction equipment Rationale: The nurse should anticipate that a client with a lobectomy will have a chest tube and will need suction, Vaseline gauze, and a clamp at the bedside for emergency use. Page 635 and 637

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? 1. Hyperoxygenate the client. 2. Set the suction pressure range at 150 mm Hg. 3. Place the catheter into the tracheostomy tube. 4. Apply suction on the catheter, and insert it into the tracheostomy tube.

1. Hyperoxygenate the client

A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle.

1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts.

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1. Rhonchi are auscultated. 2. Pleural friction rub is heard. 3. Fine crackles are auscultated. 4. Pulse oximetry reading is 96%

1. Rhonchi are auscultated. Rationale: Presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if he or she cannot expectorate them. Page 574 and 575

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right

1. Stridor Rationale: Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.

A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action? 1. Suction the client. 2. Evaluate the cuff for a leak. 3. Assess for a disconnection. 4. Notify the respiratory therapist

1. Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. Page 680

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? 1. Make sure that the client is not lying on the ventilator tubing. 2. Determine if there are any disconnections in the ventilator tubing. 3. Check to see if the client is biting on the endotracheal tube (ETT). 4. Auscultate the lungs to determine if the client needs to be suctioned.

2. Determine if there are any disconnections in the ventilator tubing Rationale: The low pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. High-pressure alarms can be triggered by increased airway resistance, such as occurs with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Page 680

A nurse is caring for a client with acute respiratory distress syndrome. What should the nurse expect to note in the client? 1. Pallor 2. Low arterial Pao2 3. Elevated arterial Pao2 4. Decreased respiratory rate

2. Low arterial Pao2 Rationale: The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg. Page 205-206, 672

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1. A 25-year-old woman with diabetic ketoacidosis 2. A 65-year-old man out of bed 1 day after prostate resection 3. A 73-year-old woman who has just had pinning of a hip fracture 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash

3. A 73-year-old woman who has just had pinning of a hip fracture Rationale: Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

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

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased CO2 2. An increased pH and a decreased CO2 3. A decreased pH and a decreased HCO3 4. An increased pH with an increased HCO3

4. An increased pH with an increased HCO3 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 to increase. Symptoms experienced by the client would include hypoventilation and tachycardia.

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? 1. It reduces the secretions in the bronchi. 2. It causes dilation of the bronchial smooth muscles. 3. It relieves pain, which helps to reduce the dyspnea. 4. It helps to reduce anxiety and oxygen consumption.

4. It helps to reduce anxiety and oxygen consumption.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Exhale slowly. 2. Stay very still. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4. Perform the Valsalva maneuver. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation

A nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A tubing obstruction or kink 2. The accumulation of secretions 3. Disconnection of the ventilator tubing 4. Condensation of water in the ventilator tubing

3. Disconnection of the ventilator tubing Rationale: The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. Options 1, 2, and 4 identify causes for triggering the high-pressure alarm. page 680

A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? 1. Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

3. Document the findings. Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore no action is necessary except to document the findings. Page 637

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1. Cardiac output of 5 L/min 2. Right atrial pressure of 9 mm Hg 3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg 4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg Rationale: Normal PCWP ranges from 8 to 15 mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the left ventricle, such as occurs in heart failure.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tubes are obstructed.

4. The chest tubes are obstructed. Rationale: Fluid in the water-seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed.

A nurse is monitoring the status of a client who is being treated for dyspnea. The nurse is aware that which factor will decrease the work of breathing for this client? 1. Bronchodilation 2. Increased airway resistance 3. Increased mucus production 4. Interstitial pulmonary edema

1. Bronchodilation Rationale: Bronchodilation decreases airway resistance and decreases the work of breathing for the client with dyspnea. Clients with dyspnea who have bronchospasm, increased mucus production, or edema exhibit increased airway resistance, which increases the work of breathing. Page 551 and 695

A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What is the best position for the nurse to place the client in for the procedure? 1. Dorsal recumbent 2. Left lateral, with the right arm supported by a pillow 3. Right side-lying, with the legs curled up into a fetal position 4. Upright and leaning forward with the arms on an over-the-bed table

4. Upright and leaning forward with the arms on an over-the-bed table Rationale: The client undergoing thoracentesis usually sits in an upright position, with the anterior thorax supported by pillows, or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion.

A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn? 1. Allen's test 2. Goodell's sign 3. Babinski reflex 4. Brudzinski's sign

1. Allen's test Rationale: Before radial artery puncture for obtaining a blood sample for ABG analysis, an Allen test should be performed to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1. Dyspnea 2. Bradypnea 3. Bradycardia 4. Decreased respirations

1. Dyspnea Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. Page 655

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH? 1. Fall 2. Rise 3. Double 4. Remain unchanged

1. Fall Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH.

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? 1. Inflate the cuff on the tracheostomy tube. 2. Deflate the cuff on the tracheostomy tube. 3. Maintain the head of the bed in low Fowler's position. 4. Place the tray in a comfortable position in front of the client.

1. Inflate the cuff on the tracheostomy tube Rationale: Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration. Page 572 and 573

A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine (Adrenalin) 4. Tracheostomy set with the next larger size

1. Obturator Rationale: A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgement occurs should also be kept at the bedside. Page 571

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1. Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation.

A nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? 1. Osmosis 2. Diffusion 3. Ionization 4. Active transport

2. Diffusion

A nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1. Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal expected finding.

2. Notify the health care provider (HCP). Rationale: Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. Page 637

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape

2. Petrolatum gauze and sterile 4 × 4 gauze

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system. 4. Place a sterile dressing over the disconnection site.

2. Place the tube in a bottle of sterile water. Rationale: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias

3. Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

3. Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Displacement of the endotracheal tube

4. Displacement of the endotracheal tube Rationale: The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses. Page 637

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10."

1. "It hurts more when I breathe in." Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration. Page 551

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1. Absence of dyspnea 2. Increased severity of cough 3. Dull percussion notes over lung tissue 4. Decreased tactile fremitus over lung tissue

1. Absence of dyspnea Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism? 1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting 3. Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts 4. Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time

1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance Rationale: IMV/SIMV is one of the methods used for weaning. With this method the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation.

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? 1. Notify the health care provider (HCP). 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage.

1. Notify the health care provider (HCP). Rationale: Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the HCP is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the HCP places the client at risk. Page 592

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. 1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting

1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting

The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL and determines that the tidal volume indicates which factor? 1. The amount of air delivered with each set breath 2. A breath that has a greater volume than the preset tidal volume 3. The number of breaths that the client will receive per minute by the ventilator 4. The fraction of inspired oxygen (Fio2) that is delivered to the client through the ventilator

1. The amount of air delivered with each set breath Rationale: Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. The respiratory rate is the number of breaths to be delivered by the ventilator. The Fio2 delivered to the client is indicated by the Fio2 indicator on the ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. Page 678

A nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse plans care, anticipating that which physical response will initially occur? 1. The client's pH will fall. 2. The client will lose consciousness. 3. The client's sodium and chloride level will rise. 4. The client will complain of facial numbness and tingling.

1. The client's pH will fall. Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. Page 196-197, 200

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client stops spontaneous breathing.

1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Pco2 50 mm Hg 2. pH 7.35, Pco2 40 mm Hg 3. pH 7.50, Pco2 52 mm Hg 4. pH 7.52, Pco2 28 mm Hg

1. pH 7.25, Pco2 50 mm Hg

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2. Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider. This instruction is based on the understanding that the endotracheal tube could enter which respiratory structures? 1. Left main bronchus if inserted too far 2. Right main bronchus if inserted too far 3. Left main bronchus if not inserted far enough 4. Right main bronchus if not inserted far enough

2. Right main bronchus if inserted too far Rationale: If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. Page 675

A nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse determines that the tube is positioned above which area of the respiratory system? 1. The first tracheal cartilaginous ring 2. The bifurcation of the right and left main bronchi 3. The point at which the larynx connects to the trachea 4. The area connecting the oropharynx to the laryngopharynx

2. The bifurcation of the right and left main bronchi Rationale: The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation. Page 664, 674-675

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? 1. "I need to protect the stoma from water." 2. "Soaps should be avoided near the stoma." 3. "I should use diluted alcohol on the stoma to clean it." 4. "I should apply a non-oil-based ointment to the skin surrounding the stoma."

3. "I should use diluted alcohol on the stoma to clean it." Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort 3. Accumulation of respiratory secretions 4. Generation of extreme negative pressure by the client

3. Accumulation of respiratory secretions Rationale: The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 4 identify causes for triggering the low-pressure alarm. page 680

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. Suctioning is required frequently. 2. The client's skin and mucous membranes are light pink. 3. Aspiration of gastric contents occurs during suctioning. 4. Excessive secretions are suctioned from the tube and stoma.

3. Aspiration of gastric contents occurs during suctioning. Rationale: Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents.

A nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider states that as a result of fluid in the alveoli, surfactant production is falling. The nurse understands that which is the natural consequence of insufficient surfactant? 1. Atelectasis and viral infection 2. Bronchoconstriction and stridor 3. Collapse of alveoli and decreased compliance 4. Decreased ciliary action and retained secretions

3. Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Page 671

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 1. Bradypnea 2. Flattened neck veins 3. Decreased cardiac output 4. Hyperresonance to percussion 5. Tracheal deviation to the opposite side

3. Decreased cardiac output 4. Hyperresonance to percussion 5. Tracheal deviation to the opposite side Rationale: Tension pneumothorax is the rapid accumulation of air in the pleural space. This causes extremely high intrapleural pressures resulting in tension on the heart and great vessels. This can cause decreased cardiac output (tachycardia, hypotension), hyperresonance on percussion, and a tracheal shift away from the affected side. Page 683-684

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope in which location? 1. Near the lateral 12th rib 2. In the fifth intercostal space 3. Just under the left-sided clavicle 4. Posteriorly, under the left-sided scapula

3. Just under the left-sided clavicle Rationale: For the client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded uppermost part of the lung Page 683

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report should the nurse expect to note, that are consistent with this disorder? 1. Pao2 58 mm Hg, Paco2 32 mm Hg 2. Pao2 60 mm Hg, Paco2 45 mm Hg 3. Pao2 49 mm Hg, Paco2 52 mm Hg 4. Pao2 73 mm Hg, Paco2 62 mm Hg

3. Pao2 49 mm Hg, Paco2 52 mm Hg Rationale: Respiratory failure is described as a Pao2 of 60 mm Hg or lower and a Paco2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (Paco2) from the client's baseline are considered diagnostic.

The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure? 1. Pao2 65 mm Hg 2. Paco2 70 mm Hg 3. Pao2 55 mm Hg 4. Paco2 60 mm Hg

3. Pao2 55 mm Hg Rationale: Respiratory failure is defined as a Pao2 of 60 mm Hg or lower when the client is receiving oxygen of 60% or greater. Common causes of hypoxemic respiratory failure are pneumonia, pulmonary embolism, and shock. Hypercapnic respiratory failure is defined as a Paco2 of greater than 45 mm Hg and an arterial pH of less than 7.35. Examples of causes of hypercapnic respiratory failure are chronic obstructive pulmonary disease, brainstem injuries, chest wall disorders, and neuromuscular disorders.

A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside? 1. Intubation tray 2. Morphine sulfate injection 3. Portable chest x-ray machine 4. Chest tube and drainage system

4. Chest tube and drainage system Rationale: Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse should have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. Page 560-561

The nurse determines the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1. Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal during inspiration and expiration

4. Continuous bubbling is observed in the water seal during inspiration and expiration Rationale: Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of re-expansion of the lung or obstruction or kinking of the chest tube Page 637

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem? 1. Silence the alarm to avoid disturbing the client. 2. Check the ventilator circuit for any disconnections. 3. Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4. Empty excess accumulated water from the ventilatory circuit tubing

4. Empty excess accumulated water from the ventilatory circuit tubing Rationale: High-pressure alarms can be triggered by increased airway resistance caused by excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Excess water should be emptied from the tubing. Alarms should never be silenced until the cause has been identified and corrected. Additionally, this will not eliminate the problem. The low-pressure alarm would sound with a disconnection. Filling the cuff to 25 mm Hg can result in impaired circulation to the tracheal mucosa. Page 680

A client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. A nurse who is trying to enhance the client's respiratory status should avoid which action? 1. Keeping the head of the bed elevated 2. Monitoring the flow rate of supplemental oxygen 3. Assisting the client to turn, cough, and breathe deeply 4. Encouraging the client to breathe slowly and shallowly

4. Encouraging the client to breathe slowly and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange.

A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention should the nurse implement? 1. Administering atropine intravenously 2. Administering small doses of a sedative 3. Encouraging additional fluids for the next 24 hours 4. Ensuring the return of the gag reflex before offering food or fluids

4. Ensuring the return of the gag reflex before offering food or fluids Rationale: After bronchoscopy, the nurse keeps the client on NPO (nothing by mouth) status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles