Respiratory System AQ Review

Restlessness and dyspnea are signs of what?

cerebral hypoxia

What are clinical findings specific to profound hypothermia (temp lower than 87)

-Absent reflexes -Profound bradycardia -Fixed, dilated pupils

Common causes of pleural effusion are:

-CHF -Pneumonia -Pulmonary embolism -Malignancy

The nurse is caring for a client that has a tracheostomy tube with a high-volume, low-pressure cuff. The cuff prevents what?

-Mucosal necrosis

ARDS results in inadequate cerebral oxygenation producing what symptoms?

-Restlessness -Confusion -Dilated pupils (with hypoxia) -Tachypnea

What are clinical findings specific to moderate hypothermia? (temp 87-90)

-Rigidity -Slowed respiratory rate -Bradycardia -Metabolic and respiratory acidosis -Hypovolemia

What are clinical findings specific to mild hypothermia?

-Confusion -Lethargy -Shivering (disappears at temp lower than 92) (temp 90-95)

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply.

-Prevent the client's blanket from covering the adaptor's orifices (The adaptor's orifices allow RA to combine with the oxygen to provide a specific oxygen concentration.) -Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask. (A venturi mask uses one of several adaptors, which are usually color-coded, to deliver the prescribed FiO2)

The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter?

-Readings in the green zone mean that my asthma is under control -If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital -I should check the peak flow readings at least twice a day -If a reading in the yellow zone occurs, the client should use the reliever drug and then measure the peak expiratory flow (PEF) again in a few minutes to determine whether the drug is working. -Clients need to check the PEF any time a reliever drug is used to determine the drug's effectiveness

The client with asthma is at risk for what ABG disorder?

Respiratory acidosis r/t hypoxia

The nurse is providing postoperative care to a client that had a pneumonectomy. The nurse should monitor the client closely for what specific complication that is associated with this type of surgical procedure?

Signs of cardiac overload -Loss of the large vascular lung or the presence of a mediastinal shift can result in cardiac overload.

The stimulus to breath in the emphysema patient is not illicited by elevated CO2 levels, but instead the respiratory center responds to lowered _____________ levels

oxygen *Therefore, supplemental oxygen levels must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe.

If the client is walking the hallway and pulls his chest tube out due to confusion, what action should the nurse take immediately?

Cover the opening with the cleanest material available

A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply.

Crackles, cyanosis, frothy sputum

When auscultating the lungs of a COPD patient, the nurse can expect to hear what?

Diminished breath sounds

Percussion over dense tissue, such as bone or muscle, causes what sound?

Flat sound

Pulmonary edema is a complication of what cardiac disorder?

Left-sided heart failure.

The nurse assesses a client through the use of percussion and notes resonance. This finding is consistent with assessment of what?

Lungs - Percussion over air-filled lung tissue causes a resonant sound.

Percussion over a solid organ, such as the liver or heart, causes what sound?

Dull

Inadequate chest expansion can be caused by pleural effusion? T or F?

True

T or F: The pt with a chest tube should not lie with the HOB elevated

True. This position does not stimulate deep breathing and gravity keeps secretions lower in the lungs.

History of patient with TB

-Fever -Night Sweats -Blood-tinged sputum -Productive cough

For what complication should the nurse monitor the asthmatic pt for?

Atelectasis. As a result of narrowed airways, adequate ventilation of lung tissue is compromised and alveoli may collapse.

What interventions should the nurse anticipate will be prescribed for a client who has a leak of the thoracic duct following radical neck surgery? Select all that apply.

-Bed rest to conserve energy (recommended because lymphatic flow increases with activity) -Chest tube to drain the fluid (chest tube drains the leaking chyle from the thoracic area). -TPN to boost immune defenses

A client has a hysterectomy, salpingoophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations should the nurse assess the client that indicates that the client may be experiencing a pulmonary embolus? Select all that apply.

-Decreased O2 sat -Sudden onset of SOB

What are signs of pulmonary embolus?

-Dyspnea (due to increased alveolar dead space, which impedes ventilation) -hemoptysis -Chest pain -Feeling of impending doom (chest pain and dyspnea cause this) -Apprehensive and hyperalert -Crackles may be heard on auscultation

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion?

-Extension of cancerous lesions Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

Hemoptysis & Night Sweats

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

-Apply a precut dressing around the insertion site with the flaps pointing upward (To prevent raveling and potential aspiration into the airway, only a precut dressing should be used around the site. It should be positioned to collect expectorations)

Describe the purpose of each chamber in a three-chamber underwater drainage system

-First chamber collects drainage -Second chamber provides for the underwater seal -Third chamber controls the amount of suction. *All three chambers allow for escape of air bubbles

A client with chronic obstructive pulmonary disease has a blood pressure of 90/60, a weak pulse, and anxiety. The nurse should place the client in which position?

HOB elevated about 10 degrees -A slightly elevated HOB facilitates breathing while preventing further hypotension

What respiratory complication r/t splenectomy will the nurse assess for post-op?

Inadequate lung aeration -Because of the location of the spleen, postoperative pain will cause splinting and shallow breathing and underaeration of the left lung's lower lobe.

What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy?

Keep the stoma covered with a scarf. This allows air in and keeps dirt out.

A client is on bed rest and develops bronchitis and atelectasis of the right lower lobe. The nurse provides teaching about the treatment plan and explains that the recommended client position is:

Lying on the left (unaffected) side to promote drainage facilitates full expansion of the affected area and promotes drainage by gravity.

A client with pulmonary tuberculosis is being treated at home. To help control the spread of the disease, the nurse instructs the client to:

Open windows frequently to allow air to circulate throughout the house... lowering the concentration of microorganisms

What complication that may arise post-op after the insertion of a central venous catheter that causes the client to complain of chest pain and causes decreased breath sounds on the affected side?

Pneumothorax. Administer oxygen immediately! s&s include: chest pain, dyspnea, apprehension, cyanosis, decreased breath sounds on affected side. Confirmed by abnormal chest x-ray findings.

A client is scheduled for coronary artery bypass surgery. The nurse explains to the client that chest tubes will be inserted during surgery to:

Reestablish negative intrapleural pressure -During chest surgery the negative pressure around the lung is disrupted and the lungs do not fill adequately during inspiration; chest tubes are inserted to reestablish negative intrapleural pressure.

A client with an acute emphysemic episode is dyspneic and anxious. To decrease the dyspnea, the nurse's first action is to:

Teach the client rhythmic breathing permits more complete exhalation and emptying of CO2 from the lungs

Percussion over the air-filled stomach causes what sound?

Tympany

What cardiac complication is common with thoracic surgeries?

Cardiac irregularities with premature beats

The nurse understands that clients with emphysema experience which pathophysiological change in the lungs?

Clients with emphysema experience changes in the alveolar sacs when they lose elasticity. Trapped air causes the sacs to become distended and can cause them to rupture. This in turn impairs gas exchange.

A nurse is suctioning a client's tracheostomy.

1. Auscultate the lungs and check the heart rate 2. Turn suction on to between 80-120 mm Hg pressure 3. Hyperoxygenate using 100% oxygen 4. Don sterile gloves 5. Guide the catheter into the tracheostomy tube using a sterile gloved hand

The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. The nurse considers that the main purpose of the third chamber of the underwater drainage system is to:

Control the amount of suction.

How much serosingouness drainage would you expect to see in a drainage catheter post-op in 24h?

80-100mL expected in the first 24 h (more than this should be reported)

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication?

Palpating the neck or face (Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue)