CH 21 Lower Respiratory Disorders
A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? 1) "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." 2) "Hold the spirometer at your lips and breathe in and out like you normally would." 3) "Take a deep breath and then blow short, forceful breaths into the spirometer." 4) "When you're ready, blow hard into the spirometer for as long as you can."
"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Explanation: The client should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The client should then exhale slowly through the mouthpiece.
A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate? 1) "A large amount of fluid has accumulated in your lungs and made it difficult to breathe." 2) "Bacteria have entered the fluid surrounding your lungs and these bacteria must be eliminated." 3) "Fluid has built up between your lungs and the lining that surrounds your lungs." 4) "The small air sacs that make up your lungs have become infected."
"Fluid has built up between your lungs and the lining that surrounds your lungs." Explanation: A pleural effusion is characterized by an accumulation of fluid in the pleural space. This excess fluid is not located in the lung tissue itself or in the alveoli. A pleural effusion is not normally infectious in etiology.
The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment? 1) "I seem to get nearly every cold and flu that goes around my workplace." 2) "Lately, I have this cough that just never seems to go away." 3) "I find that I don't have nearly the stamina that I used to." 4) "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."
"Lately, I have this cough that just never seems to go away." Explanation: 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.
A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response? 1) "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." 2) "The type of treatment depends on the patient's age and health status." 3) "The type of treatment depends on what the patient wants when given the options." 4) "The type of treatment depends on the discussion between the patient and the health care provider over which treatment is best."
"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." Explanation: The objective of management is to provide a cure, if possible. Treatment depends on the cell type, the stage of the disease, and the patient's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend primarily on the patient's age, or the patient's preference between the different treatment modes. The decision surrounding treatment does not depend solely on a discussion between the patient and the health care provider over which treatment is best, although patient preferences are an important consideration.
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? 1) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." 2) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." 3) "You must consume a diet rich in protein, such as chicken, fish, and beans." 4) "You must consume a diet low in fat by limiting dairy products and concentrated sweets."
"You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? 1) Reddened area 2) 5-mm induration 3) 15-mm induration 4) A blister
15-mm induration Explanation: A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 1) 1 to 3 weeks 2) 2 to 4 months 3) 6 to 12 months 4) 3 to 5 days
6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? 1) Impaired gas exchange 2) Decreased cardiac output 3) Anxiety 4) Ineffective tissue perfusion (cardiopulmonary)
A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? 1) A client with a nasogastric tube 2) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago 3) A client who is receiving acetaminophen (Tylenol) for pain 4) A client who ambulates in the hallway every 4 hours
A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
Which would be least likely to contribute to a case of hospital-acquired pneumonia? 1) A highly virulent organism is present. 2) Host defenses are impaired. 3) Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. 4) A nurse washes her hands before beginning client care.
A nurse washes her hands before beginning client care. Explanation: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.
A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? 1) Pneumonia 2) Acute respiratory failure 3) Pleural effusion 4) Pneumoconiosis
Acute respiratory failure Explanation: 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.
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? 1) Administer a subcutaneous injection into each child's umbilical area. 2) Administer intradermal injections into each child's inner forearm. 3) Administer a subcutaneous injection at a 45-degree angle into each child's deltoid. 4) Administer intramuscular injections into each child's vastus lateralis.
Administer intradermal injections into each child's inner forearm. Explanation: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
Who is the FluMist vaccine is not recommended for? Select all that apply. 1) have diabetes. 2) are undergoing chemotherapy treatment. 3) have renal disease. 4) All of the options are correct.
All of the options are correct. Explanation: The FluMist vaccine is not recommended for people with underlying medical conditions such as diabetes or renal dysfunction, people with known or suspected immunodeficiency diseases or those receiving immunosuppressive therapy, people with a history of Guillain-Barré syndrome, children or adolescents who regularly take aspirin, pregnant women, and people with a hypersensitivity to eggs. Reference:
The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition? 1) Emphysema 2) Asthma 3) Pneumonia 4) Pleurisy
Asthma Explanation: Wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.
A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? 1) Correct use of a mini-nebulizer 2) Correct technique for rhythmic breathing 3) Correct use of a ventilator 4) Correct use of incentive spirometry
Correct use of incentive spirometry Explanation: Instruction in the use of incentive spirometry begins before surgery to familiarize the client with its correct use. You do not teach a client 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 nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? 1) Sibilant wheezes 2 Low-pitched rhonchi during expiration 3) Pleural friction rub 4) Crackles in the lung bases
Crackles in the lung bases Explanation: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? 1) Daily doses of isoniazid, 300 mg for 6 months to 1 year 2) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years 3) Isolation until 24 hours after antitubercular therapy begins 4) Nothing, until signs of active disease arise
Daily doses of isoniazid, 300 mg for 6 months to 1 year Explanation: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.
The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax? 1) Muffled heart sounds 2) Sudden loss of consciousness 3) Diminished or absent breath sounds on the affected side 4) Paradoxical chest wall movement with respirations
Diminished or absent breath sounds on the affected side Explanation: 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.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? 1) Ascites 2) Syncope 3) Hypertension 4) Dyspnea
Dyspnea Explanation: Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? 1) Increased dietary intake of protein 2) Maintaining the client in a supine position 3) Early ambulation 4) Administering aspirin with warfarin
Early ambulation Explanation: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.
Which intervention does a nurse implement for clients with empyema? 1) Institute contact precautions 2) Keep suspected clients apart. 3) Encourage breathing exercises. 4) Allow visitors with respiratory infection
Encourage breathing exercises. Explanation: The nurse teaches the client with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions and isolate suspected and clients with confirmed influenza in private rooms or place suspected and confirmed clients together. The nurse does not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? 1) Encouraging increased fluid intake 2) Turning the client every 2 hours 3) Elevating the head of the bed 30 degrees 4) Maintaining a cool room temperature
Encouraging increased fluid intake Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? 1) Perform chest auscultation. 2) Monitor pulse oximetry readings. 3) Obtain serial ABG samples. 4) Monitor incentive spirometry volumes.
Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? 1) Promote the client's ability to take in oxygen 2) Promote more efficient and controlled ventilation and to decrease the work of breathing 3) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing 4) Promote the strengthening of the client's diaphragm
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? 1) Positive end-expiratory pressure (PEEP) 2) Incentive spirometry 3) Intermittent positive pressure-breathing (IPPB) 4) Bronchoscopy
Incentive spirometry Explanation: 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 PEEP, continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used.
The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? 1) Intermittent positive-pressure breathing (IPPB) 2) Positive end-expiratory pressure (PEEP) 3) Bronchoscopy 4) Incentive spirometry
Incentive spirometry Explanation: 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 clients 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 medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's health care provider because these symptoms are suggestive of what issue? 1) Pneumothorax 2) Infection 3) Lung tumors 4) Pulmonary edema
Infection Explanation: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? 1) Perform nasopharyngeal suctioning. 2) Administer analgesics as ordered. 3) Initiate oxygen therapy. 4) Administer a heparin bolus and begin an infusion at 500 units/hour.
Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? 1) Borderline 2) Uncertain 3) Positive 4) Negative
Negative Explanation: The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? 1) Hypoxemia 2) Dyspnea 3) Orthopnea 4) Hemoptysis
Orthopnea Explanation: Orthopnea is the term used to describe a client's inability to breathe easily except in an upright position. Orthopnea may occur in clients with heart disease and, occasionally, in clients with COPD. Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.
Which is a key characteristic of pleurisy? 1) Anxiety 2) Dyspnea 3) Pain 4) Blood-tinged secretions
Pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.
A client in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter should the nurse monitor most closely on a client who is postoperative following an embolectomy? 1) Pressure in the vena cava 2) Lung function testing 3) White blood cell differential 4) Pulmonary arterial pressure
Pulmonary arterial pressure Explanation: If the client has undergone surgical embolectomy, the nurse measures the client's pulmonary arterial pressure and urinary output. Pressure is not monitored in a client's vena cava. White cell levels would be monitored, but not to the extent of the client's pulmonary arterial pressure. Lung function testing cannot be carried out on an acutely ill postsurgical client.
A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? 1) Chronic obstructive pulmonary disease (COPD) 2) Empyema 3) Pulmonary tuberculosis 4) Pulmonary hypertension
Pulmonary hypertension Explanation: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.
The most diagnostic clinical symptom of pleurisy is: 1) Dullness or flatness on percussion over areas of collected fluid. 2) Dyspnea and coughing. 3) Stabbing pain during respiratory movements. 4) Fever and chills.
Stabbing pain during respiratory movements. Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? 1) Streptococcus pneumoniae 2) Pseudomonas aeruginosa 3) Staphylococcus aureus 4) Mycobacterium tuberculosis
Streptococcus pneumoniae Explanation: Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? 1) Tachypnea 2) Cough 3) Syncope 4) Hemoptysis
Tachypnea Explanation: Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).
A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize? 1) The importance of adhering to the prescribed treatment regimen 2) The correct use of a metered-dose inhaler (MDI) for bronchodilators 3) The rationale and technique for using incentive spirometry 4) The need to maintain good nutrition and adequate hydration
The importance of adhering to the prescribed treatment regimen Explanation: Successful treatment of TB is wholly dependent on the patient's conscientious adherence to treatment. Patient education relating to this fact is a priority over MDIs, incentive spirometry, or nutrition, although each may be necessary.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? 1) The patient has a pneumothorax. 2) The chest tube is obstructed. 3) The system has an air leak. 4) The system is functioning normally.
The system has an air leak. Explanation: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
A water seal system for chest drainage has been inserted into a patient who suffered chest trauma during a motor vehicle accident. At the beginning of the night shift, the nurse has entered the patient's room to assess the system and the patient's condition. Which of the following assessment findings suggests that the system is operating correctly and the patient is maintaining oxygenation? 1) The water level in the water seal chamber increases when the patient inhales. 2) The level in the water seal chamber stays constant throughout the ventilation cycle. 3) There is constant bubbling in the water seal chamber. 4) The water level reaches the top of the water seal chamber with each breath
The water level in the water seal chamber increases when the patient inhales. Explanation: The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Water levels should at no time reach the top of the water seal chamber.
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? 1) Use a heat or cold application. 2) Avoid using a pillow while splinting. 3) Turn onto the affected side. 4) Use a prescribed analgesic.
Turn onto the affected side Explanation: Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.
The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. 1) Applying a sequential compression device 2) Instructing the client to move the legs in a "pumping" exercise 3) Using elastic stockings, especially when decreased mobility would promote venous stasis 4) Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day 5) Encouraging a liberal fluid intake
Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Explanation: The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.
The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: 1) oxygen saturation level. 2) hemoglobin, hematocrit, and red blood cell levels. 3) level of consciousness (LOC). 4) extremities for signs of cyanosis.
oxygen saturation level. Explanation: The effectiveness of the client'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 client'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 physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as 1) pneumothorax. 2) pleural effusion. 3) hemothorax. 4) consolidation.
pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.
What should a nurse pay careful attention to when monitoring a client with acute respiratory failure? Select all that apply. 1) signs of cyanosis 2) respiratory rate and depth 3) signs of flushing 4) response to treatment
respiratory rate and depth signs of cyanosis response to treatment explanation When caring for a client with acute respiratory failure, the nurse must pay particular attention to respiratory rate and depth, signs of cyanosis, other signs and symptoms of respiratory distress, and the client's response to treatment. The nurse monitors ABG results and pulse oximetry findings and implements strategies to prevent respiratory complications, such as turning and ROM exercises.
