Respiratory Saunders

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?

I should use diluted alcohol on the stoma to clean it."

The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease?

It can be caused by the inhalation of spores from bird droppings.

The 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. How does the nurse correctly interpret these findings?

It is at the bifurcation of the right and left main bronchi.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make?

The client's test result will be positive, and a chest x-ray study will be required for evaluation.

The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

A client who is intubated and receiving mechanical ventilation is at 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.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

"Blocked nasal passages impair the sense of smell."

The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?

"I should perform arm exercises 2 or 3 times a day."

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 with this goal. Which client statement indicates that further instruction is needed?

"I will lie on the affected side for an hour."

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?

"It hurts more when I breathe in."

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching?

"It will keep the small airways open."

A health care provider (HCP) 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 registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made?

"The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client?

"The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication?

A kink in the ventilator circuit

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

A shunt unit exists.

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?

Absence of dyspnea

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

Accumulation of pleural fluid in the inflamed area

The 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?

Accumulation of respiratory secretions

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?

Adjust the oxygen depending on SpO2.

The nurse should determine that tracheal suctioning is needed if which is noted?

Congested breath sounds in the lung fields

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?

Contact the health care provider (HCP).

The nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer?

Cough

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff on the tube.

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action?

Determine if there are any disconnections in the ventilator tubing.

Which are warning signs of head and neck cancer? Select all that apply.

Difficulty swallowing Lump in the mouth, neck, or throat 4. Persistent or unexplained oral bleeding

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?

Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

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?

Displacement of the endotracheal tube

The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action?

Document the accurate functioning of the tube.

The 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 drainage system. Which nursing action is appropriate?

Document the findings.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply.

Dry air, Exercise, An upper respiratory infection (URI), Nonsteroidal antiinflammatory drugs (NSAIDs)

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

Dyspnea

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

Dyspnea

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply.

Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions Prolonged expiratory breathing phase

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?

Eat foods that are highly seasoned in moderation.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem?

Empty excess accumulated water from the ventilatory circuit tubing.

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system?

Ensure the water level in the water seal chamber is at the 2-cm level.

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply.

Fatigue 2. Malaise 3. Anorexia

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

Flushing Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction?

Hold the gum between the cheek and teeth periodically.

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?

Increased respiratory rate

Which are possible causes of upper airway obstruction? Select all that apply.

Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client?

Low arterial PaO2

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

Lung crackles in the remaining lung

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning?

Lying on the back in a low Fowler's position

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

Maintain inflation of the alveoli.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action?

Moves downward and out

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm?

Moves downward and out as it contracts

The 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?

Notify the health care provider (HCP).

The 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?

Obturator

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?

Petrolatum gauze and sterile 4 × 4 gauze

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

Provide nasotracheal suctioning as needed to remove secretions.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?

Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

Rapid, shallow respirations

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?

Respiratory rate of 16 breaths/minute

The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period?

Serosanguineous

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time?

Several weeks to months

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.

Suctioning the client as needed 2. Encouraging coughing every 2 hours Supporting the neck incision when the client coughs 5. Monitoring the respiratory status frequently as prescribed

A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure?

Take a deep breath and hold it.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply.

Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy.

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation?

The chest tube is functioning as expected.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

The chest tube may be obstructed.

A client tells the nurse that the health care provider (HCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder?

The client has reduced lung volume and fibrosis on chest x-ray.

The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply.

The drainage in the collection chamber marked each shift to monitor the amount of drainage The dry suction control regulation set to the prescribed amount

The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics?

The drainage is bloody.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding?

There is an air leak somewhere in the system.

The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply.

fatigue, lethargy, morning cough, low-grade fever

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside?

intubation tray

The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas?

lobes

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing?

lying on the back in a low Fowler's position

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement?

"I will discard used tissues in a plastic bag."

A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status?

Respiratory rate of 22 breaths/min

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?

Rhonchi are auscultated.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

plan short sessions with the client to obtain data.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply.

Cigarette smoking 3. Genetic risk factor 4. Environmental factors Alpha-1 antitrypsin (AAT) deficiency

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments?

"I cannot give Legionnaires' disease to other people."

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed?

"I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

"I should not be contagious after 2 to 3 weeks of medication therapy."

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

"That isn't done because people often would develop pneumonia from the constricting effect on the lungs."

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note?

Complaints of night sweats

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result?

Negative

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?

The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder?

The inflamed pleurae cannot glide against each other as they normally do.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?

Tripod position

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L

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.

Clamp, Vaseline gauze, Suction equipment

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 (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

"It will enter the right main bronchus if inserted too far."

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Continue to monitor the client.

The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?

Continuous bubbling is observed in the water seal chamber during inspiration and expiration.

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?

Dyspnea

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis?

A man who is an inspector for the U.S. Postal Service

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing?

Administer the prescribed bronchodilator.

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?

Allow the inner cannula to dry after washing it with sterile water.

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?

Aspiration of gastric contents occurs during suctioning.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

Bronchospasm

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply.

Chills and night sweats Cough 2. Dyspnea

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect?

Collapse of alveoli and decreased compliance

The 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 (HCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

Collapse of alveoli and decreased compliance

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action?

Document the findings.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Document the findings. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

Dyspnea Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?

Exposure to tuberculosis

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose?

Humidifies the oxygen that is bypassing the client's nose

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client?

Hyperinflation of lungs documented by chest x-ray

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?

Hyperoxygenate the client.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority?

Inability to clear the airway related to inability to expectorate sputum

The nurse should provide which home care instructions to a client who had a laryngectomy and has a stoma? Select all that apply.

Increase the humidity in the home. 2. Obtain and wear a MedicAlert bracelet. 3. Wear clothing that does not cover the stoma. 4. Stay away from people who have a respiratory infection. 5. Be careful with showering to avoid water entering the stoma.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate?

Increase to 3 L/min and titrate until the SpO2 is 88%

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

Instruct the client to avoid coughing and deep breathing.

The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube?

It could enter the right main bronchus if inserted too far.

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply.

Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Sit upright in the bed or in a chair.

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area?

Pleural space

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately?

Stridor

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first?

Suction the client through the endotracheal tube.

The 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?

Suction the client.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? Suctioning the client every hour 2. Applying suction only during withdrawal of the catheter 3. Hyperventilating the client with 100% oxygen before suctioning 4. Applying suction intermittently during withdrawal of the catheter

Suctioning the client every hour

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.

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. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly?

The client breathes out slowly through the mouth.

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?

A 73-year-old woman who has just had pinning of a hip fracture

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1. A low arterial PCo2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?

Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply.

Anosmia 2. Chronic cough 3. Purulent nasal discharge

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak, because the bubbling should be intermittent. Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

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

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 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 notification of the health care provider. 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.

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply.

Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever Eat fruits and vegetables high in vitamin C.

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which co-existing condition in the client may cause an inaccurate pulse oximetry reading?

Hypotension

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?

Inflate the cuff on the tracheostomy tube.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?

It is painless and safe.

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. How does the nurse interpret this setting?

It is the amount of air delivered with each set breath.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply.

Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

Perform a focused respiratory assessment. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system are not indicated at this time. Continuing to monitor delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

Stop the procedure and reoxygenate the client.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action?

Suction the ET tube. Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis.

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

The nurse places 1 finger loosely between the tie and the neck.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

The respiratory muscles relax.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

This is expected, and the client should gradually increase activity as tolerated.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

Tidaling is present.

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. 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 ceasing spontaneous breathing

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

The 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?

disconnection of the ventilator tubing

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position?

simi fowlers