Respiratory Quiz- EVOLVE
The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure? 1. Don sterile gloves. 2. Auscultate the lungs and check the heart rate. 3. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 4. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. 5. Hyperoxygenate using 100% oxygen.
ANS: 2, 3, 5, 1, 4 Rationale: The status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without negative pressure.
In which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism? 1. Administer unfractionated heparin. 2. Obtain blood for coagulation studies. 3. Place client on cardiac monitor. 4. Check oxygen saturation using pulse oximetry. 5. Administer oxygen to keep saturation higher than 93%.
ANS: 4, 5, 3, 2, 1, Rationale: The initial action for a client with dyspnea and chest pain will be obtain a baseline oxygen saturation and then start oxygen administration. Because dysrhythmias can occur because of hypoxemia secondary to pulmonary embolus, the nurse will start cardiac monitoring. Rapid administration of anticoagulants is needed, but baseline coagulation studies are needed prior to starting anticoagulation.
When caring for a client who has hemopneumothorax and a chest tube, which prescribed action by the health care provider would the nurse question? A. Autotransfuse the blood in the collection chamber after 6 hours. B. Disconnect the drainage system from suction to ambulate the client. C. Add sterile water to the suction control chamber to maintain 20 cm of suction. D. Use a dressing impregnated with petroleum jelly around the chest tube insertion site.
ANS: A Autotransfusion of blood from the collection system helps decrease the need for transfusion, but autotransfusion is not recommended of blood that has been in the system for more than 4 hours. B- The suction control chamber can be disconnected from wall suction to ambulate the client; negative pressure in the intrapleural space is maintained by the water-seal chamber and will not be affected by disconnecting the suction. C- Fluid in the suction control chamber frequently evaportes and needs to be replenished; 20 cm of suction is commonly prescribed. D- Dressings impregnated with petroleum jelly are frequently used around chest tube insertion sites to prevent air from entering the pleural space.
To prevent potential aspiration, which technique would the nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula? A. Apply precut dressing around the insertion site with the flaps pointing upward. B. Replace the tube with a sterile obturator. C. Use sterile cotton balls to cleanse the outer cannula. D. Remove the cannula after the high-volume, low-pressure cuff has been deflated.
ANS: A Rationale: A precut dressing is used to prevent raveling and potential aspiration of small particles of the gauze into the airway. Only a precut dressing should be used around the site and should be positioned to collect expectorations. B- An obturator is used only for inserting the outer cannula. C- The use of sterile cotton balls to cleanse the outer cannula is contraindicated; cotton balls have small threads that may be inhaled. D- The status of the cuff has no effect on tracheostomy care.
Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period? A. Provide a means for the client to write. B. Allow time to lip read what the client says. C. Deflate the cuff on the tracheostomy tube to allow verbalization. D. Remind the client that speech is possible after partial laryngectomy.
ANS: A Rationale: After laryngeal surgery, the initial communication is through writing, use of picture boards, and computer applications. B- Lip reading is an option, but takes more time for the client and nurse and is likely to be frustrating to use. C- Deflation of the cuff in the immediate postoperative time would be avoided because of the high risk for aspiration. D- Although the ability to speak will be available with partial laryngectomy, the client currently is breathing through a tracheostomy and will not be able to speak.
When a client has had laryngectomy and radical neck dissection, which action should the nurse include in the postoperative plan of care? A. Suction tracheostomy tube as needed. B. Avoid suture care for the first 24 hours. C. Keep head of bed at 30 degrees or less. D. Discourage forceful coughing efforts.
ANS: A Rationale: After laryngectomy, clients will have a tracheostomy or laryngectomy tube in place and may need suction to effectively clear the airway. B- Suture care should be done every few hours for the first few days after laryngectomy to prevent suture line infection and poor wound healing. C- Elevation of the head of the bed helps decrease swelling of the incision sites and improve ventilation. D- The client is encouraged to cough and deep breathe to help clear secretions.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? A. Client reports stools are black B. Oxygen saturation is 93%. C. Respiratory rate is 25 breaths per minute. D. Client has an ecchymosis on the ankle.
ANS: A Rationale: Because anticoagulaten use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the HCP and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. B- An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. C- A slightly elevated respiratory rate in a client with pulmonary embolus is a compensatory mechanism to prevent hypoxemia. D- Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.
The nurse is administering an intradermal tuberculosis skin test to a client. Which action would the nurse take after the medication has been injected and the needle withdrawn? A. Place a piece of gauze over the injection site. B. Scrub the site with povidone-iodine solution. C. Vigorously wipe the area with an alcohol wipe. D. Circle the area with a skin pen.
ANS: A Rationale: Gently placing a piece of gauze at the injection site is necessary to prevent the intradermal medication from leaking out of the injection site. B & C- Scrubbing the site with providone-iodine or vigorously wiping with alcohol can cause the medication to leak into the surrounding tissue and prevent the accuracy of the test. D- Circling the area with a skin pen needs to be done 48 to 72 hours after injection when identifying the amount of induration that occurs in reaction to the agent.
A client with which diagnosis will be at risk for development of a pulmonary embolism? A. Atrial fibrillation B. Forearm laceration C. Migraine headache D. Respiratory infection
ANS: A Rationale: Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. B- A foream laceration does not increase pulmonary embolism risk. C- Pulmonary embolism is not a complication of migraine headache. D- Respiratory infections do not increase pulmonary embolism risk.
A parent of three young children has contracted tuberculosis. Which medication would the nurse anticipate being prescribed for members of the family who have been exposed? A. Isoniazid B. Multiple-puncture test C. Bacille Calmette-Guerin D. Tuberculin purified protein derivative
ANS: A Rationale: Isoniazid is used as a prophylactic agent for people who have been exposed to tuberculosis; also, it is one of several medications used to treat the disease. B- Multiple-puncture tests, such as the tine test are used to test for tuberculosis; these are no longer recommended. They are not a treatment for the prevention or cure of tuberculosis. C- Bacille Calmette-Guerin is a vaccine that provides limited immunity; it is not recommended for the use in the United States. D- Tuberculin purified protein derivative, the Mantoux test, is a widely used skin test for detecting tuberculosis; it is not a treatment for the prevention or treatment of tuberculosis.
A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? A. Suction the tracheostomy. B. Change the tracheostomy tube. C. Readjust the tracheostomy tube and tighten the ties. D. Perform a complete respiratory assessment.
ANS: A Rationale: Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem-solving may require readjustment of the tracheostomy tube and ties or a health care provider changing the tracheostomy tube.
Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. A. Administer prescribed analgesic medications. B. Check around chest tube insertion site for crepitus. C. Clamp the chest tube before the client ambulates. D. Add fluid to the suction control chamber as needed. E. Milk the tubing toward the collection chamber. F. Check for air bubbling in the water-seal chamber.
ANS: A, B, D, F
The nurse is caring for clients in the pulmonary unit and suspects that one has tuberculosis (TB). Which nursing intervention is highest priority in this situation? A. Move the client to an airborne isolation unit. B. Emphasize hand washing after handling soiled tissues. C. Inform the client about adherence with the prescribed regimen. D. Report the client's condition to the primary health care provider.
ANS: A Rationale: The nurse should shift a client suspected of having TB to the airborne isolation unit as soon as possible to prevent the chances of spreading infection to other clients. B- Teaching the client about personal hygiene such as washing hands after handling soiled tissues is a medium priority. C- The nurse should inform the client about adherence with the prescribed regimen only when the diagnosis is confirmed and treatment provided by the primary health care practitioner. D- The nurse should report the client's condition to the primary health care practitioner immediately after ensuring the safety of the other clients.
Which action would the nurse include in the plan of car of a client on the first postoperative day after total laryngectomy? A. Position client in semi-Fowler position while in bed. B. Remind client that coughing may slow wound healing C. Change pressure dressings and packing every 12 hours D. Assist client with head and neck range-of-motion exercises.
ANS: A Rationale: The semi-Fowler position helps maintain the head in functional body alignment, avoids tension on the suture lines, and facilitates respiration. B- Although the client may need suctioning in the immediate postoperative period to help maintain the airway, coughing is encouraged to help expel respiratory secretions. C- Because pressure dressings help decrease swelling of the surgical area, dressings and wound packing would only be changed if prescribed by the health care provider. D- Head and neck exercises may be needed later in the postoperative process, but would not be done initially to avoid placing tension on the suture line.
A client who had thoracic surgery is admitted to the postanesthesia care unit. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which step would the nurse take next? A. Ensure the security of the connections from the client to the drainage unit. B. Empty the drainage container and measure and record the amount. C. Verify that there is vigorous bubbling in the wet suction control compartment. D. Check that the fluid level in the water-seal compartment increases with expiration.
ANS: A Rationale: The system must remain airtight (closed) to prevent collapse of the lung. B- The system is kept closed; a record of drainage is kept by marking the outside of the container or chamber. C- It should bubble, but not vigorously; vigorous bubbling will not increase the suction but will cause the fluid to evaporate more rapidly. D- The water level will fluctuate as the client inhales and exhales. The level will increase with inspiration and decrease with expiration; this is known as tidaling.
Which actions will the nurse take when caring for a client with possible lung cancer who has just had a thoracentesis? Select all that apply. One, some, or all responses may be correct. A. Listen to breath sounds. B. Encourage deep breaths. C. Send pleural fluid to the laboratory. D. Ensure that a chest x-ray is performed. E. Place the client on bed rest for the next 4 hours.
ANS: A, B, C, D Rationale: A- Breath sounds should be verified in all lung fields after thoracentesis to rule out lung collapse. B- The client is encouraged to perform deep breaths to help expand the lungs. C- Pleural fluid will be sent to the laboratory to look for malignant cells. D- A chest x-ray should be obtained after the procedure to check for pneumothorax. E- There is no need for the client to remain on bed rest after the procedure.
Which intervention would the nurse recommend to decrease tuberculosis (TB) in the community? Select all that apply. A. Improving financial resources B. Eliminating overcrowded housing C. Initiating needle-sharing programs D. Improving access for food pantries E. Providing barrier contraceptive devices
ANS: A, B, C, D, E Rationale: Factors that increase the incidence of TB in communities include HIV infection, poverty, overcrowded living conditions, malnutrition, smoking, and drug and alcohol use. Improving financial resources would benefit clients living in poverty. Addressing the overcrowded housing situation would help decrease the transmission of TB. The nurse would need to address HIV transmission. This would be by implementing needle sharing programs and providing barrier contraceptive devices as these can decrease the incidence of HIV. Improving access to food pantries can improve nutrition.
Which actions will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. A. Administer oxygen at high flow rates. B. Notify the Rapid Response Team C. Lower the head of the client's bed. D. Place the client on a cardiac monitor. E. Anticipate rapid administration of warfarin.
ANS: A, B, D Rationale: A- Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. B- The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. D- Cardiac monitoring is needed because the client is at risk for dysrhythmias. C- The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. E- Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonart embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin.
A client with COPD is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? A. Administer opioids frequently. B. Assess for signs of pneumonia. C. Give medication to suppress coughing. D. Limit fluid intake to prevent pulmonary edema.
ANS: B Rationale: Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. A- Opioids are contraindicated because opioids depress respirations. C- Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. D- Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.
After a thoracentesis performed in an outpatient setting, which client statements indicate that the nurse's teaching about possible postprocedure complications has been effective? Select all that apply. One, some, or all responses may be correct. A. "I'll go to the hospital if I start to feel more short of breath." B. "If I feel palpitations, I'll go to the emergency department." C. "Bruising at the site is an emergency and I'll call for an ambulance." D. "I will need to take my temperature daily for the next week." E. "Acetaminophen or ibuprofen can be used if I have pain at the site."
ANS: A, B, E Rationale: A & B- Complications of thoracentesis include pneumothorax and fluid shifts into the pleural space, causing hypotension and tachycardia. The client statements about going to the hospital for increased shortness of breath or palpitations indicate a good understanding of the discharge teaching. E- Acetaminophen and ibuprofen are safe to use for pain at the thoracentesis site. C- Bruising at the site may occur, but it is not an emergency and does not require treatment. Thoracentesis is done using sterile technique and infection is not a common complication. D- The client does not need to check for elevated temperature for a week.
Which instructions would the nurse provide a client prescribed rifampin for tuberculosis (TB)? Select all that apply. A. "You should report any yellow tinge to your skin." B. "Your soft contact lenses will be stained permanently." C. "You should report any reddish orange tinge to your secretions." D. "You need to drink at least 8 ounces of water with the medication." E. "You should report any increased tendency to bruising or bleeding."
ANS: A, B, E Rationale: Rifampin is a first-line medication in the treatment of TB, and clients should report and yellow tinge to the skin because this may be a sign of liver toxicity or failure. Staining of bodily fluids such as tears, urine, and swear, is commonly associated with rifampin, so warning the clients who use contact lenses of staining side effects will be beneficial. The nurse should instruct the client to report any increased tendency to bruise or bleed immediately, because this may indicate liver toxicity or damage. D- The need to drink at least 8 ounces of water with the medication is beneficial information for a client prescribed pyrazinamide. C-A reddish orange tinge to secretions is common with rifampin and not harmful, so the client does not need to report the color change.
Which actions will the nurse take when preparing a client before thoracentesis? Select all that apply. One, some, or all responses may be correct. A. Assist the client to sit up on the edge of the bed. B. Remind the client not to eat before the procedure. C. Instruct the client to rest the arms on the bedside table. D. Verify that the client has signed the informed consent form. E. Educate the client about when to cough during the procedure.
ANS: A, C, D Rationale: A- The client is usually positioned sitting up at the side of the bed or seated facing backward on a chair so that the posterior thorax is exposed. C- The client will rest the arms on the bedside table, which increases the size of the intercostal spaces. D- Informed consent is needed before thoracentesis. B- Because no sedation or general anesthesia is needed for thoracentesis, the client does not need to refrain from eating before the procedure. E- The client should be instructed to avoid coughing or moving during the procedure to decrease risk for pneumothorax.
During the evening after a thoracentesis, the client reports anxiety. Which action would the nurse take first? A. Administer the prescribed analgesic. B. Listen to the client's breath sounds. C. Give the client the prescribed as needed lorazepam. D. Ask the client about specific concerns or worries.
ANS: B Listen to the client's breath sounds. Because anxiety is frequently an early manifestation of hypoxemia, the nurse's initial action will be to assess for complications of thoracentesis such as pneumothorax by listening for lung sounds. A. Administering an analgesic may be indicated if the client states that pain is contributing to anxiety, but would be done after further assessment. C. Administration of lorazepam may be indicated after the nurse assesses for potential physiological or psychological causes of anxiety. D. Asking about specific client concerns or worries is indicated once the nurse is sure that physiological factors are not the cause of the anxiety.
A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read."m The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes the result? A. "The result indicates that you have active tuberculosis." B. "The result indicates that you are infected with the tuberculosis organism." C. "The result Indicates that there are no tuberculin antibodies in your system." D. "The result indicates that you have a secondary infection related to the tuberculin organism."
ANS: B Rationale: An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis. The other choices are incorrect.
Which room assignment would the nurse select for a child hospitalized with newly diagnosed tuberculosis? A. Private room B. Isolation room C. Four-bed room D. Semiprivate room
ANS: B Rationale: An isolation room is a private room fitted with special air handling and ventilation to prevent the transmission of airborne droplet nuclei 5 micrometers or smaller. It has monitored negative pressure to prevent air from moving from the room into the corridor of the facility. Room air is exchanged 6 to 12 times an hour to the outdoors or through a monitored high-efficiency filtration system. Mycobacterium tuberculosis remains suspended in the air for prolonged periods and is transmitted in air currents. A- A private room does not have the technical equipment to manage airborne droplet nuclei of 5 micrometers or smaller. Other children and people on the unit will be exposed to the infected individual's pathogens that travel through air currents. C & D- A four-bed room or semiprivate room will expose the children and other people on the unit to the infected individual's pathogens.
The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolus? A. Limit the client's fluid intake. B. Teach the client how to exercise the legs. C. Encourage the use of the incentive spirometer. D. Maintain the knee gatch position at an angle.
ANS: B Rationale: The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. A- Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. C- An incentive spirometer improves pulmonary function, but does not prevent venous stasis. D- Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.
When suctioning a client with a tracheostomy, which nursing intervention is correct? A. Hyperventilate the client with room air before suctioning. B. Apply suction only as the catheter is being withdrawn. C. Insert the catheter until the cough reflex is stimulated. D. Remove the inner cannula before inserting the suction catheter.
ANS: B Rationale: Use of suction on withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should be inserted only approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. A- Hyperventilating a client before suctioning should always be with oxygen, not room air. C- Inserting the catheter until the cough reflex is stimulated frequently occurs and does help mobilize secretions, but is not a safety measure. D- Removal of the inner cannula before inserting the suction catheter is not necessary.
Which educational statements from the nurse will be beneficial for the client with tuberculosis? Select all that apply. A. "Take the daily tuberculosis medication dose during daytime hours." B. "Avoid exposure to any inhalation irritants." C. "Eat foods that are rich in protein and vitamins C and B." D. "Cover the mouth and nose with a tissue when coughing or sneezing." E. "Sputum specimens are not required once medication therapy is initiated."
ANS: B, C, D Rationale: B- A client with tuberculosis should avoid exposure to any inhalation irritants because these can cause further lung damage. C- To increase physical stamina, the client should eat a well-balanced diet that includes foods that are rich in iron, protein, and vitamins C and B. D- While coughing or sneezing, the client should cover the mouth and nose with a tissue to prevent spread of infection. A- A client with tuberculosis should take the daily dose at nighttime to prevent nausea. E- Sputum specimens are usually needed every 2 to 4 weeks once the medication therapy is initiated. When the results of three consecutive sputum cultures are negative, it indicates that the client is no longer infectious.
Which actions will the nurse include when doing tracheostomy care? Select all that apply. A. Suction the client before starting tracheostomy care. B. Use sterile technique when cleaning the inner cannula. C. Use sterile cotton-tipped swabs to clean the inner cannula. D. Don sterile gloves before removing the inner cannula. E. Use hydrogen peroxide to clean the skin around the stoma.
ANS: B, D Rationale: B- Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. D- Sterile gloves are worn when removing the inner cannula. A- There is no need to suction the client before starting tracheostomy care, although the client may be preoxygenated before removing the inner cannula. C- A brush is used to clean the inner cannula. E- Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.
Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. A. Diarrhea B. Anorexia C. Weight gain D. Hemoptysis E. Night sweats
ANS: B, D, E Rationale: Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. Signs include a persistent cough, anorexia, hemoptysis, night sweats, shortness of breath, and a high body temperature. Diarrhea and weight gain are not associated with tuberculosis.
Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. A. Immobilize the left arm in a sling B. Check the water- seal chamber for air bubbling C. Avoid use of nonsteroidal anti-inflammatory drugs. D. Keep the client on bed rest in semi-Fowler position. E. Observe frequently for drainage in the collection chamber. F. Assist the client to cough and deep breathe every hour while awake.
ANS: B, F Rationale: B- The nurse would assess for air bubbling in the water-seal chamber to determine whether the client's pneumothorax is resolved. F- Hourly coughing and deep breathing helps reexpand the lung and prevents atelectasis. A- Immobilization of the left arm is not needed and may lead to decreased shoulder and arm function. C- Nonsteroidal anti-inflammatory drugs are helpful in decreasing pain from the chest tube. D- Bed rest is not needed and would increase risk for complications such as deep vein thrombosis. E- With a pneumothorax, there will be minimal drainage in the collection chamber.
After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up large amounts of thicker mucus for the past several days."
ANS: C "I get a sharp, stabbing pain when I take a deep breath." Rationale: Tension is placed on the pleura at the height of inspiration and causes pain. A. The response "Lately I can only breathe well if I sit up" is typical of heart failure." B. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. D. The response "I'm coughing up large amounts of thicker mucus for the past several days" may indicate a pulmonary infection.
Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the most rapid action by the nurse? A. Oxygen saturation of 93% B. Blood pressure of 160/94 mm Hg C. Decreased right side breath sounds D. Ecchymosis at the site of the thoracentesis
ANS: C Decreased right breath sounds After thoracentesis the breath sounds should be audible on the affected side and decreased breath sounds may indicate pneumothorax. The nurse would immediately notify the health care provider and expect actions such as a chest x-ray and possible insertion of a chest tube. A. The oxygen saturation of 93% is slightly below normal, but would not be surprising in a client who has a history of lung disease. B. Hypotension after thoracentesis may indicate bleeding or that too much pleural fluid has been removed at once, but mild hypertension may occur due to anxiety or pain. D. Ecchymosis at the thoracentesis site would be monitored, but would be expected after thoracentesis.
Which action would the nurse take first when caring for a client with a possible pulmonary embolus? A. Auscultate the chest. B. Obtain the vital signs. C. Elevate the head of the bed. D. Notify the rapid response team.
ANS: C Elevating the head of the bed promotes better gas exchange by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. A- The nurse will auscultate the chest, but breath sounds are not initially changed with pulmonary embolus, which affects pulmonary circulation, but not ventilation. B- Heart rate and rhythm, blood pressure, and respiratory rate are likely to be affected by pulmonary embolism, but the nurse's first action would be to attempt to improve oxygenation by elevating the head of the bed. D- The rapid response team would be rapidly notified, but the initial action would be to elevate the head of the bed to improve oxygenation.
Which nursing action is of the highest priority when a client's chest tube has accidentally dislodged? A. Place the client in a left side-lying position. B. Apply oxygen via nonrebreather mask. C. Apply a petroleum gauze dressing over the site. D. Prepare to insert a new chest tube.
ANS: C Rationale: A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The health care provider should be notified immediately and the client assessed for signs of respiratory distress. A- Positioning the client on the left side will not make a difference in outcome. B- There is no indication that the client is experiencing respiratory distress. D- Preparing to insert a new chest tube is not a priority of the nurse at this moment.
When caring for a patient with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? A. Chest x-ray B. Thoracic ultrasound C. Helical computed tomography (CT) D. Magnetic resonance imaging (MRI)
ANS: C Rationale: Helical CT is the most commonly used to detect pulmonary embolism. A- Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool. B- Thoracic ultrasound might be used for pleural effusion, but not to diagnose pulmonary embolism. D- MRI testing is not used for diagnosis of pulmonary embolism.
The registered nurse (RN) is delegating care for a client who underwent a tracheostomy. Which task could be delegated to the licensed practical nurse (LPN)? A. Developing a plan to avoid aspiration B. Assessing the client's condition after tracheostomy C. Providing tracheostomy care using sterile techniques D. Teaching a client and caregiver about home tracheostomy care
ANS: C Rationale: The licensed practical nurse (LPN) provides tracheostomy care using sterile techniques. A- Developing a plan to avoid aspiration in a client with tracheostomy is done by the RN. B- Assessing the client's condition after tracheostomy is done by the RN. D- Teaching a client and caregiver about home tracheostomy care is done by the RN.
Which type of adventitious breath sound would the nurse expect when auscultating the posterior chest of a client with pleurisy who is reporting sharp chest pain with deep breathing? A. Stridor B. Rhonchi C. Pleural friction rub D. High-pitched crackles
ANS: C Rationale: Pleurisy is caused by inflammation of the pleural surfaces, and a frequent clinical manifestation is a pleural friction rub, which is a rough, scratching, grating, creaking sound caused by inflamed pleural surfaces rubbing together. It is frequently associated with chest pain. A- Stridor is a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear. B- Rhonchi are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality that occur with partial bronchial obstruction caused by mucus, bronchospasm, foreign bodies, or tumors. D- High pitched crackles are fine, short, interrupted popping sounds best heard on inspiration that occur with problems such as heart failure when air passes through fluid within the alveoli.
After a laryngectomy, a client asks, "When can I learn how to speak again?" Which is the best response by the nurse? A. "Every client with a laryngectomy is different. It's difficult to say." B. "It must be difficult for you, but be patient. These things take time." C. "Perhaps you would like to start working with the speech therapist today." D. "I will give you some written information describing esophageal speech."
ANS: C Rationale: The client's statement indicates readiness to develop a plan to regain speech, and the speech therapist's role is to assess the client, then develop and implement a plan to regain speech. A- The statement, "Every client with a laryngectomy is different. It's difficult to say," is an evasive answer and offers no plans for goal setting. B- Initially, the response, "It must be difficult for you, but be patient. These things take time," identifies feelings, but does not answer the client's question. D- Written information can be helpful, but the nurse does not know whether esophageal speech is a good option for this client.
The nurse caring for a client who has had a hysterectomy is concerned about the client's risk for postoperative thrombosis. The nurse remembers that, after pelvic surgery, the majority of pulmonary emboli begin as deep vein thromboses in which area? A. Calf B. Thoracic cavity C. Pelvis and thighs D. Extremities and abdomen
ANS: C Rationale: Most pulmonary emboli after surgery of the pelvic floor originate in the deep veins of the pelvis and thighs because of the extensive vascular network in the region. The calf, thoracic cavity, extremities, and abdomen are not where most pulmonary emboli originate after surgery involving the pelvic floor.
The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A. A column of water 20 cm high in the suction control chamber. B. 75 mL of bright red blood in the drainage collection chamber. C. An intact occlusive dressing at the insertion site D. Constant bubbling in the water-seal chamber
ANS: D Rationale: Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an unexpected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.
The nurse is assessing four different clients. Which client is at risk of pleuritis? Client A: Crackles (Sound), Right and left lung bases (Site) Client B: Rhonchi (Sound), Over trachea and bronchi (Site) Client C: Wheezes (Sound), Overall lung fields (Site) Client D: Pleural friction rub (Sound) Over anterior lateral lung field (Site)
ANS: D Rationale: Inflammation of the pleura is known as pleuritis. In this condition, a pleural friction rub sound can be heard prominently over the anterior lateral lung field, as in the case of client D. Client A has a crackling sound in the right and left lung bases; this osund may be caused by the reinflation of groups pf alveoli. Client B has rhonchi sounds over the trachea and bronchi, which may be due to muscular spasm in the larger airways. Client C has wheezing sounds over the lung fields. This sound indicates an obstructed airway.
Which action would the nurse take first when doing preoperative teaching for a client who is scheduled for a total laryngectomy? A. Arrange for a speech therapist visit. B. Provide an explanation of the surgery. C. Develop a plan for communication after surgery. D. Ask what questions the client has about the procedure.
ANS: D Rationale: The first action when preparing to teach a client is to assess the client's current knowledge level and client priorities for learning. A- A speech therapy visit may be scheduled preoperatively, but the nurse would first assess whether the client would find the visit helpful. B- An explanation of the surgery would be provided by the nurse (although a detaIled explanation would be done by the surgeon doing the surgery), but this would be done after assessing the client's current knowledge and learning needs. C- A plan for communication after surgery is certainly needed, but this would be developed after determining the client's preferences.
Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. A. Emptying the drainage system when full B. Keeping the drainage system at heart level C. Notifying the health care provider of drainage greater than 50 mL/h D. Marking the time on the drainage unit every shift E. Laying the drainage system on its side during transport
ANS: D Rationale: The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. A- Emptying the system would break sterility. B- The drainage system should remain below chest level to prevent fluid from backing up into the lungs. C- The nurse would notify the health care provider if drainage is greater than 100 mL/h. E- The nurse would keep the drainage system upright.
A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client? A. Private room B. Semiprivate room C. Room with windows that can be opened D. Negative-airflow room
ANS: D Rationale: Tuberculosis is an airborne contagious disease that is best contained in a negative-airflow room. Negative-airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.
Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? Select all that apply. One, some or all responses may be correct. A. Using hydrogen peroxide B. Inserting a catheter without suction C. Placing the client in the recumbent position D. Rinsing the inner cannula with normal saline E. Changing both tracheostomy ties at same time
ANS: D Rationale: When removing the inner cannula, it must be rinsed with normal saline. A- Hydrogen peroxide Is only used if an infection is present. B- A catheter is inserted into the cannula when suctioning. C- The client would be placed in the semi-Fowler position. E- The nurse would change one tracheostomy tie at a time to ensure that the cannula stays in place.
A client is prescribed rifampin after being exposed to active tuberculosis. Which finding would the nurse immediately report to the HCP? Select all that apply. A. Reddish-orange color urine B. Yellow-colored teeth stains C. Orange-colored sweat and tears D. Small, red, pinpoint areas on the arms E. Numbness, tingling, and burning of extremities
ANS: D Rationale: Pinpoint red areas that appear on the arms, legs, or trunk of the body are known as petechiae. The petechiae are tiny hemorrhages that occur under the skin as a result of a low circulating platelet count (thrombocytopenia). Thrombocytopenia occurs with liver stress or damage. As hepatotoxicity is a possible adverse reaction to rifampin, the HCP must be notified of the appearane of petechiae.
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. The nurse assesses the fluid in the system and recognizes that which finding indicates that the chest tube is functioning properly? A. The fluid remains constant in the chest drainage chamber. B. The fluid is bubbling gently in the chest drainage chamber. C. The fluid is bubbling vigorously in the suction control chamber. D. The fluid rises in the tube of the water-seal chamber during inspiration.
ANS: D The fluid rises in the tube of the water-seal chamber during inspiration. Increased negative intrapleural pressure on inspiration causes the fluid to rise; a decrease in negative intrapleural pressure on expiration causes the fluid to fall. A. Remaining constant in the chest drainage chamber indicates that an obstruction is present in the drainage tubing or that the suction is too low; a slight increase in fluid should be evident in this chamber postoperatively. B. Bubbling gently in the chest drainage chamber indicates an air leak. C. If the water is bubbling vigorously in the suction control chamber, the suction is too hight; bubbling should be gentle.
Which finding best indicates that the chest tube for a client with a pneumothrax may be discontinued? A. Clear breath sounds heard in both lungs B. Oxygen saturation reading is higher than 90%. C. Absence of bubbling in the water-seal chamber D. Full re-expanison of the lungs senn on chest x-ray
ANS: D Rationale: Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence of pneumothorax. A- Clear breath sounds heard bilaterally do help indicate that the lung has re-expanded, but a chest x-ray is needed to confirm lung re-expansion. B- Oxygen saturation improve with resolution of pneumothorax, but a chest x-ray is needed for confirmation. C- Because intrapleural air is expelled into the water-seal chamber, lack of bubbling in the water-seal chamber indicates possible resolution of the pneumothorax, but a chest x-ray is needed for confirmation.
