Respiratory

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? a. a client with epistaxis b. a client who has amyotrophic lateral sclerosis c. a client who has pneumonia d. a client who has emphysema

A. The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse in ED is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? a. Apply supplemental O2 b. Increase the rate of IV fluids c. Administer pain medication d. Initiate cardiac monitoring

A. When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? a. "i will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." b. "i will notify the provider if there is continuous bubbling in the water seal chamber." c. "i will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." d. "i will notify the provider if there are several small, dark-red blood clots in the tubing."

B. Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? a. rhonchi on inspiration b. elevated temperature c. barrel shaped chest d. diminished breath sounds

B. The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of O2? a. nasal cannula b. nonrebreather mask c. simple face mask d. partial rebreather mask

B. The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse in a providers office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? a. Increased anterior-posterior chest diameter. b. Productive cough with green sputum. c. Clubbing of the fingers. d. Pursed lip breathing with exertion

B. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? a. schedule respiratory treatments following meals b. have the client sit up in a chair for 2-hr periods three timer per day. c. provide a diet that is high in calories and protein. d. combine activities to allow for longer rest periods between activities.

C. The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is caring for a client who is 1 hour Post Op following a thoracentesis. Which of the following is the priority assessment finding? a. pallor b. Insertion site pain c. persistent cough d. temp of 37.3 C (99.1 F)

C. When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? a. blood pressure b. cap refill c. ABG d. Heart rate

C. When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse in ED is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? a. Arterial pH 7.50 b. PaCO2 25 mm Hg c. SaO2 92% d. PaO2 58 mm Hg

D. The nurse should expect the client to have lower partial pressures of oxygen.

A nurse working in an emergency dept is caring for a client following an acute Chest Trauma. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? a. collapsed neck veins on the affected side b. collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side

D. The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). which of the following findings should the nurse report to the provider? a. decreased bowel sounds b. oxygen saturation 92% c. CO2 24 mEq/L d. intercostal retractions

D. The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? Select All that apply. a. wear goggles and mask during the procedure b. cleanse the procedure area with an antiseptic solution c. Instruct the client to take deep breaths during the procedure. d. position the client laterally on the affected side before the procedure. e. Apply pressure to the site after the procedure.

a, b, c, d, & e Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.