2861 exam 2

thoracotomy

surgical incision into the chest wall.

empyema

the collection of pus in a cavity in the body, especially in the pleural cavity.

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response?

"This cancer usually does not spread to distant sites in the body."

pleural effusion

A buildup of fluid between the tissues that line the lungs and the chest.

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home?

A humidification system

A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?

B) The tonsils help to guard the body from invasion of organisms.

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

Correct use of incentive spirometry Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

the maximal volume of air inhaled after normal expiration.

Inspiratory capacity

The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition?

It can cause life-threatening airway obstruction. Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work or reduced cardiac function.

The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up?

Periorbital edema Referral to a physician is indicated if periorbital edema and severe pain on palpation occur.

The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?

Shortness of breath Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.

The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?

Teach him how to perform huffing. The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?

Tidal volume

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?

"Lately, I have this cough that just never seems to go away." The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections and fatigue are not characteristic early signs of lung cancer.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

"The younger you are when you start smoking, the higher your risk of lung cancer."

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

20 cm H2O

The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurse's best response?

A PFT measures how much air moves in and out of your lungs when you breathe.

The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patient's sternum. This patient's health record should note the presence of what chest deformity?

A funnel chest A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patient's nutrition during treatment?

A liquid or soft diet

hypotensive

A systolic blood pressure of less than 90 millimeters of mercury (mm Hg) or diastolic of less than 60 mm Hg is generally considered to be hypotension.

A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?

A tracheostomy In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.

A) Post thoracotomy B) Spontaneous pneumothorax D) Chest trauma resulting in pneumothorax Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What might this indicate?

A) The patient has a narrowed airway. Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?

Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

Adequate flow of blood through the pulmonary circulation.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?

An adequate ventilationperfusion ratio

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?

Anticoagulant therapy usually lasts between 3 and 6 months. Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?

Apply ice and keep the patient's head elevated.

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?

Assess the patient's lung sounds and SAO2 via pulse oximeter. Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?

Assess the patient's oxygen saturation level. The effectiveness of the patient's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patient's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?

Assist the patient into a position that will allow gravity to move secretions.

The nurse has assessed a patient's family history for three generations. The presence of which respiratory disease would justify this type of assessment?

Asthma Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication?

Atelectasis A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

While planning a patient's care, the nurse identifies nursing actions to minimize the patient's pleuritic pain. Which intervention should the nurse include in the plan of care?

Avoid actions that will cause the patient to breathe deeply. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

Baseline arterial blood gas (ABG) levels Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient's record, and the nurse can refer to them before the weaning process begins.

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?

Between 15 and 20 mm Hg

While assessing an acutely ill patient's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?

Biot's respiration The nurse will document that the patient is demonstrating a Biot's respiration pattern. Biot's respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot's respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea.

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient's symptoms from those of a cardiac etiology?

Brain natriuretic peptide (BNP) level Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?

Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.

An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care?

Cautious hydration Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?

Chest auscultation Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.

The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient?

Chest wall invasion

The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess?

Confusion and lethargy Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure. The other listed signs and symptoms are not specific to this problem.

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?

Correct and safe use of oxygen therapy equipment

A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?

Crackles Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.

The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?

D) Shunting Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.

A gerontologic nurse is analyzing the data from a patient's focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change?

Decreased diffusion capacity for oxygen The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?

Diminished or absent breath sounds on the affected side In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

Dyspnea and substernal pain

While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patient's voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?

Egophony This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?

Emphysema High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.

The nurse is creating a plan of car for a patient diagnosed with acute laryngitis. What intervention should be included in the patient's plan of care?

Encourage the patient to limit speech whenever possible. Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm cloths on the throat will not help relieve the symptoms of acute laryngitis.

The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?

Faint breath sounds with prolonged expiration The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.

. A patient's total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process?

Fitting for a voice prosthesis

The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?

Fracture of the cribriform plate Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum.

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?

Hoarseness Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching?

How to perform diaphragmatic breathing Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?

How to splint the incision when coughing

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?

Hypovolemia secondary to leakage of fluid into the interstitial spaces

The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient?

In case of recurrence, apply direct pressure for 15 minutes.

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following?

Increase fluid intake. For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying a mustard poultice will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.

. A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Increase oral fluids unless contraindicated. The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the student's nose continues to bleed. Which intervention should the nurse next implement?

Insert a tampon in the affected nare A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down on the cot could block the client's airway. Hospital admission is necessary only if the bleeding becomes serious.

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication?

It inhibits the release of histamine and other chemicals. Cromolyn (Nasalcrom) inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.

A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?

It lubricates the movement of the thorax and lungs.

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?

Keep a complete suction setup at the bedside.

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis?

Lung fields dull to percussion, absent breath sounds, and a pleural friction rub Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.

The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care?

Maintaining the patient's chest tube Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patient's unstable health status.

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the patient's oxygen saturation

mediastinotomy

Mediastinotomy is surgical opening of the mediastinum.

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?

Monitor cuff pressure every 8 hours. The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowler's position is not indicated.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia. The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. Mortality from pneumonia in the elderly is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.

A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patient's resonating chamber in speech?

Paranasal sinuses A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?

Perform shoulder exercises five times daily. The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?

Perfusion Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acidbase balance.

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient's history is most likely to have caused the empyema?

Pneumonia Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?

Preparing to assist with intubating the patient A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

Pulmonary function studies

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient's arterial oxygen saturation (SaO2). What procedure will best accomplish this?

Pulse oximetry

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?

Removal from the ventilator, tube, and then oxygen The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?

Sinus infections

An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care?

Suction the patient's airway secretions. As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with non-small cell tumors is what?

Surgical resection Surgical resection is the preferred method of treating patients with localized non-small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?

The importance of adhering closely to the prescribed medication regimen Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?

The maximal volume of air exhaled from the point of maximal inspiration

A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?

The patient's tissue demands may be met, but she will be unable to respond to physiological stressors. With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude?

The system has an air leak. Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?

Tracheoesophageal puncture Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.

A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?

Turn the patient to enable assessment of all the patient's lung fields. Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?

Use of warm saline gargles or throat irrigations can relieve symptoms. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105ºF to 110ºF (40.6ºC to 43.3ºC). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis.

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?

Venturi mask The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?

Wait several minutes and then repeat suctioning. If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?

Withhold food and fluids for several hours before the test. Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.

dyspnea

difficult or labored breathing.

The arterial oxygen tension (partial pressure or PaO2)

indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation.

ARDS

occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs.

The volume of air in the lungs after a maximal inspiration

total lung capacity