Respiratory System Nclex Review 2
A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? 1. Administer prescribed analgesic medication for incisional pain 2. Encourage use of incentive spirometer every 2 hours while awake 3. Offer an additional pillow to splint the incision while coughing 4. Promote increased oral fluid intake
A: 1. Administer prescribed analgesic medication for incisional pain Educational objective: The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises
The client has a chest tube for a pneumothorax. While repositioning the client for an X-ray, the technician steps on the tubing and accidentally pulls the chest tube out. The client's oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site, What is the nurse's immediate action? 1. Apply an occlusive sterile dressing secured on 3 sides 2. Apply an occlusive sterile dressing secured on 4 sides 3. Assess lung sounds 4. Notify the health care provider (HCP)
A: 1. Apply an occlusive sterile dressing secured on 3 sides Educational objective: If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the immediate action should be to apply an occlusive sterile dressing taped on 3 sides. This action decreases the risk for a tension pneumothorax by inhibiting air intake on inspiration and allowing air to escape on expiration.
The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation. Which assessment finding requires immediate action by the nurse? 1. Decrease in SpO, from baseline 92% to 88% on room air 2. Expectorating blood-tinged sputum 3. Loss of appetite and recent 5 Ib (2.3 kg) weight loss 4. No bowel movement for 2 days and right lower quadrant discomfort
A: 1. Decrease in SpO, from baseline 92% to 88% on room air Educational objective: Clients with cystic fibrosis are at risk for respiratory infection, mucus plugs, and pneumothorax. When respiratory status suddenly declines (eg, drop-in SpO2), urgent intervention (eg, physiotherapy, chest tube) is required to resolve mucus plug airway obstruction.
A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage 2. Immediately clamp the chest tube 3. Notify the health care provider 4. Request repeat hematocrit and hemoglobin levels Exhibit: Hemoglobin Chest tube Drainage Pre-operative 15 g/dL (150 g/L) Post-operative Day 1 12.5 g/dL (125 g/L) 400ml/24 hr Post-Operative Day 2 13 g/dL (130 g/L) 50ml/12 hr
A: 1. Document and continue to monitor chest drainage Educational objective: A client will usually have a chest tube in place for several days following a thoracotomy to drain blood from the pleural space. A rush of dark bloody drainage from the tube when the client coughs, turns, or is repositioned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red chest drainage indicates active bleeding and would be of immediate concern.
The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." 2. "I will move the indicator to the desired reading on the numbered scale before using the device." 3. "I will record my personal best reading, which is the average of 3 consecutive peak flow readings." 4. 'I will remember to use the device after taking my fluticasone metered-dose inhaler (MDI)."
A: 1."I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." Educational objective: The peak flow meter is used to measure PER and is most helpful for clients with moderate to severe asthma. A reading is obtained by exhaling as quickly and forcibly as possible through the mouthpiece of the device.
A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action? 1. Assess level of consciousness and lung sounds 2 Check the tightness of the straps and mask 3. Notify the healing care provider immediately 4 Remove the mask and administer supplemental oxygen
A: 2 Check the tightness of the straps and mask Educational objective: CPAP is prescribed for clients with obstructive sleep apnea in the home and clinical settings. The mask is secured with adjustable head straps to maintain a snug fit over the face to prevent air leakage and loss of positive pressure.
The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease. Which client statement indicates appropriate understanding? Select all that apply. 1. "I need to take iron supplements to prevent anemia. 2. "I should report an increase in sputum." 3. "I will eat a low-calorie diet." 4. 'I will get a pneumococcal vaccine." 5. "I will use albuterol if I am short of breath."
A: 2,4,5 2. "I should report an increase in sputum." 3. "I will eat a low-calorie diet." 4. 'I will get a pneumococcal vaccine." Educational objective: Clients with chronic obstructive pulmonary disease should be instructed to consume a high-calorie diet, seek medical attention for signs of infection (eg, increased sputum, worsening dyspnea, fever), and obtain appropriate vaccinations (g, influenza, pneumococcal) to prevent exacerbations.
The charge nurse evaluates the care provided by a new registered nurse (RN a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education? 1 Administers morphine to relieve anxiety and restlessness 2. Applies suction when inserting the catheter into the airway 3. Increases the oxygen concentration on the MV before suctioning 4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present
A: 2. Applies suction when inserting the catheter into the airway Educational objective: To minimize the removal of oxygen and mucosal trauma, suction should be applied only when removing the catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg, hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, pre-oxygenating with 100% oxygen, and limiting suction time to 10-15 seconds.
The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage 4. Performing frequent mouth care every 2 hours to help prevent infection
A: 2. Checking the tightness of ties and adjusting if necessary, allowing 1 Educational objective: The immediate postoperative priority goal for a client with a newly placed tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway.
The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? 1. Imbalanced nutrition 2. Impaired gas exchange 3. Impaired tissue integrity 4. Risk for infection
A: 2. Impaired gas exchange Educational objective: ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS
A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the R take to correct the problem? 1. Elevates the head of the bed 2. Increases the oxygen flow 3. Opens both flutter valves (ports) on the mask 4. Tightens the face mask straps
A: 2. Increases the oxygen flow of the reservoir bag. Educational objective: A non-rebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalations (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.
The nurse is assisting a client with asthma perform a peak flow meter measurement. Place the instructions for measuring peak expiratory flow using a peak flow meter in the correct order. All options must be used. 1. Exhale as quickly and completely as possible and note the reading on the scale 2. Inhale deeply, place mouthpiece in mouth, and use the lips to create the seal 3. Position the indicator on the flow meter scale to the lowest value and assume an upright position 4. Record the highest of the three measured values in the peak flow log 5. Repeat the procedure 2 more times with a 5. to 10-second rest period between exhalations
A: 3,2,1,5,4 3. Position the indicator on the flow meter scale to the lowest value and assume an upright position. 2. Inhale deeply, place mouthpiece in the mouth, and use the lips to create the seal 1. Exhale as quickly and completely as possible and note the reading on the scale 5. Repeat the procedure 2 more times with a 5. to 10-second rest period between exhalations 4. Record the highest of the three measured values in the peak flow log Educational objective: When performing peak flow measurements, set the indicator to the lowest Value, assume an upright position, inhale deeply, place the mouthpiece in the mouth and form a seal with the lips, exhale quickly and completely; note the value, repeat 2 more times;, and then record the highest value in the peak flow log.
The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. "If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing and having more trouble breathing, I will not make any changes in my medications." 2. "If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medications." 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." 4 "If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes before calling an ambulance."
A: 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." Educational objective: A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications.
The nurse is assisting the health care provider (Hcp) wh a clerts chest tute removal, Just as the HCP prepares to pull the chest tube, What instructions Should the nurse give the client? 1. "Breathe as you normally would." 2. 'Inhale and exhale slowly." 3. "Take a breath in, hold it, and bear down." 4. "Take rapid shallow breaths, similar to panting."
A: 3. "Take a breath in, hold it, and bear down." Educational objective: During chest tube removal, the client should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) to prevent air from reentering the pleural space and possibly causing a pneumothorax. The site is covered with a sterile airtight petroleum jelly gauze dressing. A post- procedure chest x-ray is needed.
The nurse in the postanesthesia care unit (PACU) is caring for an unresponsive client who just came from the operating room following surgery under general anesthetic for colorectal cancer. The nurse chooses what as the highest priority nursing diagnosis (ND)? 1. Acute pain 2. Impaired physical mobility 3. Ineffective airway clearance 4. Risk for fluid volume deficit
A: 3. Ineffective airway clearance Educational objective: Acute pain, impaired physical mobility, ineffective airway clearance, and risk for fluid volume deficit are appropriate NDs in a client in the PACU who is immediately postoperative. The highest priority ND is the one that poses the greatest threat to survival based on the client's current health status.
A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2 Non-rebreathing mask 3 Oxymizer 4. Venturi mask
A: 4 Venturi mask Educational objective: • LOW-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]). • High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type Il respiratory failure [hypercarbic]).
The nurse receives the handoff of care report on four clients. Which client should the nurse see first? 1. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago 2. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and a SpO2, of 94% on room air 3. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago 4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has a SpO2, of 93% on 4 L/min supplemental oxygen, and is becoming restless
A: 4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has a SpO2, of 93% on 4 L/min supplemental oxygen, and is becoming restless Educational objective: Acute respiratory failure is a life-threatening impairment of lung function that inhibits gas exchange. Common symptoms include altered mental status (eg, confusion, agitation, somnolence), paresthesias, dyspnea, tachypnea, and hypoxemia, all of which should be addressed immediately.
The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. Client 1-day postoperative abdominal surgery who has fine inspiratory crackles at the lung bases 2. Client with chronic bronchitis who has rhonchi in the anterior and posterior chest 3. Client with right-sided pleural effusion who has decreased breath sounds at the right lung base 4. Client with severe acute pancreatitis who has inspiratory crackles at the lung bases
A: 4. Client with severe acute pancreatitis who has inspiratory crackles at the lung bases Educational objective: Clients with acute pancreatitis are at high risk for developing acute respiratory distress syndrome.
The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm HO. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate the client for pain and document the findings 4. Notify the health care provider immediately
A: 4. Notify the health care provider immediately Educational objective: A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately.
The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin lift
A: 4. Perform head tilt and chin lift Educational objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway.
An A64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2 of 60 mm Hg (8.0 kPa), and PCO, of 80 mm Hg (10.6 kPa). Which of the following should the nurse implement first? 1. Administer PRN nebulizer treatment 2. Administer scheduled dose of methylprednisolone IV 3. Increase client's oxygen to 4 liters 4. Place client on the bilevel positive airway pressure (BIPAP) machine
A: 4. Place client on the bilevel positive airway pressure (BIPAP) machine Educational objective: BIPAP therapy is an effective treatment to decrease CO, levels in clients with hypercapnic respiratory failure.
The home health nurses visit a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider? 1. Bronchial breath sounds 2. Increased tactile fremitus 3. Low-pitched wheezing (rhonchi) 4. Pleural friction rub
A: 4. Pleural friction rub Educational objective: Pleurisy is characterized by stabbing pleuritic chest pain that increases on inspiration. It is a complication of pneumonia caused by inflamed parietal and visceral pleurae rubbing together.
The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD). The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with pathways that just allow passage from one room to another. What is the priority nursing action? 1. Call the mobile community mental health crisis unit 2. Contact a service to remove the newspapers and magazines 3. Reconcile the client's discharge medications 4. Teach the safe use of oxygen
A: 4. Teach the safe use of oxygen Educational objective: Teaching the safe use of home oxygen is the priority nursing intervention for a client with hoarding disorder who lives in an environment at high risk for fire due to the accumulation of newspapers and magazines. Hoarding disorder is the persistent difficulty with discarding possessions, no matter their value. Removal of the items will cause the client to experience severe anxiety.
A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1. Administer prescribed IV fluids 2. Apply supplemental oxygen via nonrebreather mask 3. Assist the health care provider to prepare for chest tube insertion 4.Cover the wound with petroleum gauze taped on three sides
A: 4.Cover the wound with petroleum gauze taped on three sides Educational objective: A sucking chest wound indicates a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides.
The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? 1. Clamping the chest tube at the insertion site during the transfer 2. Disconnecting the suction tubing from the wall suction unit 3. Hanging the chest tube collection unit to the underside of the stretcher 4. Taping connections between the chest tube and suction tubing
A:1 Educational objective: Chest tubes should not be clamped during transport of a client. A clamped a chest tube may cause a tension pneumothorax, a potentially life-threatening event.
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? 1. PaO2, 49 mm Hg (6.5 KPa), PaCO, 60 mm Hg (8.0 KPa) 2. PaO2, 64 mm Hg (8.5 KPa), PaCO, 45 mm Hg (6.0 kPa) 3. PaO2, 70 mm Hg (9.3 kPa), PaCO, 30 mm Hg (4.0 kPa) 4. PaO2, 86 mm Hg (11.5 kPa), PaCO, 25 mm Hg (3.33 kPa)
A:1 PaO, 49 mm Hg (6.5 KPa), PaCO, 60 mm Hg (8.0 KPa) Educational objective: Type I hypoxemic failure is associated with an alteration in O2 transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type Il hypercapnic, or ventilatory, failure is associated with CO, and retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO, < or = to 60 mm Hg (8.0 kPa), PaCO2≥50 mm Hg (6.67 kPa), and pH < or= to 7.30.
A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply. 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea 4. Hyperresonance on percussion 5. Wheezing
A:1,2,3 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea Educational objective: A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange, Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.
The nurse caring for a client with left lobar pneumonia responds to an alarm the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client i which position to improve oxygenation? 1. Left lateral 2. Right lateral 3. Supine 4 Trendelenburg
A:2. Right lateral Educational objective: Pneumonia (ie, infection of the lungs) causes decreased gas exchange in the affected lung lobes, which can lead to hypoxia and respiratory distress. Clients with unilateral pneumonia should be positioned with the unaffected (ie, good) lung down to improve perfusion and oxygenation.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool-mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed-lip breathing during the night
A:1,2,3,4 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool-mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime Educational objective: Interventions to help reduce the viscosity of mucus, facilitate secretion removal, and promote comfort in clients with chronic bronchitis including the following: • Increasing oral fluids to 2-3 L/day if not contraindicated • Cool mist humidifier to increase room humidity • Guaifenesin (Robitussin), an expectorant, to reduce the viscosity of secretions • Huff coughing
A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. 1. Accessory muscle use 2. Chest tightness 3. High-pitched expiratory wheeze 4. Prolonged inspiratory phase 5. Tachypnea
A:1,2,3,5 1. Accessory muscle use 2. Chest tightness 3. High-pitched expiratory wheeze 5. Tachypnea Educational objective: Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Clinical manifestations of an asthma exacerbation include accessory respiratory muscle use, chest tightness, diminished breath sounds, high-pitched wheezing on expiration, prolonged expiratory phase, tachypnea, and cough.
The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client
A:1,3,5 1. Auscultate breath sounds 3. Instruct client to cough and deep breathe 5. Reposition the client Educational objective: The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.
The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply. 1."Avoid the use of over-the-counter cough suppressant medicines." 2." Oral antibiotics are not needed at home as you had intravenous (IV) therapy in the hospital." 3. "Pneumonia vaccination is not needed as you now have lifelong immunity." 4 "Schedule a follow-up with the health care provider (HCP) and chest X- ray." 5 "Use a cool mist humidifier in your bedroom at night." 6 "Use the incentive spirometer at home."
A:1,4,5,6 1."Avoid the use of over-the-counter cough suppressant medicines." 4 "Schedule a follow-up with the health care provider (HCP) and chest X- ray." 5 "Use a cool-mist humidifier in your bedroom at night." 6 "Use the incentive spirometer at home." Educational objective: Discharge instructions for a client recovering from pneumonia focus on proper medication regimen, lung expansion and coughing techniques, activity level, hydration, nutrition, avoidance of tobacco products, reportable manifestations (eg, respiratory distress, chest pain, fever, cough, change in mucus), follow-up care, influenza and pneumonia vaccinations, and respiratory and hand hygiene.
The nurse caring for a client with emphysema is providing teaching for pursed lip breathing exercises. Which statement by the client indicates effective teaching? 1 "As my breathing improves, my lungs will begin to heal." 2. "Pursed lip breathing will help my airways stay open." 3. "This is a relaxation technique to help with my anxiety." 4. "This will help reduce the fluid buildup in my lungs.
A:2 Educational objective: Clients with emphysema have damaged alveoli and collapsed airways resulting in air trapping. Pursed lip breathing keeps the airway open through positive pressure during exhalation, allowing for improved airflow.
The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate? 1. Bolus dose of IV morphine 2. Incentive spirometer 3. IV furosemide 4. Non-rebreather mask
A:2 Educational objective: The incentive spirometer is a handheld, inexpensive breathing device. It encourages the client to breathe deeply with maximum inspiration, which improves ventilation and oxygenation and encourages coughing. The incentive spirometer is used to prevent or improve atelectasis in clients who are postoperative, have respiratory problems (eg, pneumonia), or have experienced trauma.
A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply. 1. Arterial pH 7.50 2. PaCO, 55 mm Hg (7.3 kPa) 3. PaO2 58 mm Hg (7.7 kPa) 4. Paradoxical breathing 5. Restlessness and drowsiness
A:2,3,4,5 2. PaCO, 55 mm Hg (7.3 kPa) 3. PaO2 58 mm Hg (7.7 kPa) 4. Paradoxical breathing 5. Restlessness and drowsiness Educational objective: Clinical manifestations indicating impending respiratory failure in clients with asthma include hypercapnia, hypoxemia, paradoxical breathing, and mental status changes.
A client with pneumonia is transferred from the medical unit to the intensive care unit due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the health care provider (HCP)? Click on the exhibit button for additional information. 1. Cough with mucus production 2. Refractory hypoxemia 3. Scattered rhonchi and crackles 4 Temperature 101 F (38.3 C)
A:2. Refractory hypoxemia Educational objective: Refractory hypoxemia is the inability to improve oxygenation with increases in oxygen concentration. It is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high mortality rate
The medical-surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action? 1. Administer a dose of prescribed prn anti-anxiety medication 2. Call the health care provider who performed the surgery 3. Call the rapid response team 4. Place the client in the left lateral recovery position
A:3 3. Call the rapid response team Educational objective: When a client is demonstrating clinical deterioration, the nurse's priority is to prevent full respiratory or cardiac arrest by calling the rapid response team.
The nurse is caring for a client with advanced heart failure in an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? 1 Administer as-needed (prn) albuterol by nebulizer 2. Administer prn intravenous (IV) furosemide 3. Elevate the head of the bed 4. Give prn sublingual morphine
A:3 Elevate the head of the bed Educational objective: The client with advanced heart failure on hospice is likely to have dyspnea associated with fluid overload. The first intervention should be to elevate the head of the bed and then assess for fluid overload, which would be treated with IV diuretics. Morphine can alleviate dyspnea associated with heart failure, but it should be used in combination with other nonpharmacologic and pharmacologic interventions.
The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply. 1 "I have been drinking alcohol almost daily since age 20." 2. "I have been overweight for as long as I can remember." 3. "I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year." 4 "I know I eat too much fast food." 5. "I was a car mechanic for about 40 years and had my own garage.
A:3,4 3. "I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year." 4 "I know I eat too much fast food." Educational objective: Chronic airway inflammation is closely associated with the development of chronic obstructive pulmonary disease. Specific etiologic factors include current or former tobacco smoking, prolonged exposure to occupational respiratory irritants, chronic exposure to air pollution, and genetic predisposition.
A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum 2. Lung sounds 3. Saturation level 4. White blood cell count (WBC)
A:4 White blood cell count (WBC) Educational objective: Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production)
