HESI Prep: Respiratory System

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct.

Mold, cold air, pet dander, air pollution & cigarette smoke - Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.

When a nurse needs to administer oxygen at a fraction of inspired oxygen (FiO2) of about 40% to keep a client's oxygen saturation greater than 94%, which method would be best?

Nasal cannula - All of the oxygen delivery methods are capable of delivering an FiO2 of 40%, but the nasal cannula is the most comfortable and least intrusive. A face tent would provide humidification, but is more intrusive and there is no indication that the client needs additional humidification. A Venturi mask is more intrusive and uncomfortable for the client. A simple face mask would be more uncomfortable for the client.

Which statement describes a client's tidal volume?

Tidal volume is the volume of air inhaled and exhaled with each breath. - Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.

Which parameter describes the maximum volume of air a client's lungs may contain?

Total lung capacity - Total lung capacity is the maximum volume of air that the lungs can contain. Vital capacity is the maximum volume of air that can be exhaled after maximum inspiration. Inspiratory capacity is the maximum volume of air that can be inhaled after maximum expiration. Functional residual capacity is the volume of air remaining in the lungs at the end of normal exhalation.

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) would be administered in which manner?

1 to 2 L via nasal cannula to keep SaO2 above 90% - Oxygen therapy usually is delayed until stage 4, which is very severe COPD. Usually it is administered at 1 to 2 L per minute to maintain SaO2 at or above 90%. One to 2 L to maintain the SaO2 above 95% is not necessary. Oxygen administration may not be necessary. Three liters of oxygen via a mask is unnecessary, and a level of 95% may suppress the hypoxic drive in clients who are chronic CO2 retainers. Oxygen should not be given unless the chronic saturation level is less than 88%.

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis?

Carina - Located at the level of the manubriosternal junction, the carina is also referred to as the angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing.

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease?

Tuberculosis - Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells; it does not cause hemoptysis.

Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin?

Client reports stools are black. - Because anticoagulant use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the health care provider and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. A slightly elevated respiratory rate in a client with a pulmonary embolus is a compensatory mechanism to prevent hypoxemia. Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.

After the nurse has finished teaching a client who is scheduled for hemilaryngectomy about ways to prevent aspiration during swallowing, which client statement indicates the need for further teaching?

"I should plan to drink more water, milk, and juices." - Risk for aspiration increases after hemilaryngectomy; water and other thin liquids are more difficult to swallow, increasing aspiration risk. Consuming smaller and more frequent meals is advised because relearning how to swallow requires concentration and is fatiguing. Consuming meals in a fatigued condition may lead to aspiration due to inadequate concentration on swallowing technique. Having suctioning equipment nearby allows rapid suctioning if aspiration occurs.

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

"Your infection occurred because of exposure to a health care facility. " - A health care-acquired infection is contracted during treatment in a health care facility, such as a hospital or nursing home. Both community-acquired and health care-acquired infections may require antibiotics. Community-acquired and health care-acquired infections may require isolation. An infection that occurred before hospitalization would be called a community-acquired infection.

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct.

Facial edema, septal deviation, clear nasal drainage, oxygen saturation 89%, & bilateral periorbital bruising - Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. "Raccoon eyes" or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.

A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. Which client assessment leads the nurse to determine that the postural drainage is effective?

Has a productive cough - A productive cough indicates that mucus is being raised from the lungs, which is an expected outcome. Crackles are unaffected by postural drainage or coughing. Saliva comes from the mouth; it does not indicate that the lungs are clear. Depth of respirations may not be altered by postural drainage.

Which is the purpose of an occlusive dressing over a client's sucking chest wound?

Maintains negative pressure within the chest cavity - An occlusive dressing helps maintain negative intrathoracic pressure by preventing air from moving into the pleural space from the open wound. Without an occlusive dressing, this wound can result in an open pneumothorax and mediastinal shift. The dressing does not protect the lung. An occlusive dressing will not affect major blood vessels, which are not located at the periphery of the lung. Other types of dressings might be used to prevent contamination, but an occlusive dressing is used to seal the chest wall and maintain negative intrapleural pressure.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise?

Promotes elimination of CO2 - Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct.

Question the client about shortness of breath. Ask the client about color and quantity of sputum. - Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration?

Wheezes - Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.

A client is admitted to the hospital with chronic asthma. Which complication would the nurse monitor in this client?

Atelectasis - As a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse (atelectasis). Pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. Pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. Respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis.

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?

Cordectomy - A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and 1 or 2 tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. Which action would the nurse take?

Cover the opening with the cleanest material available. - This emergency situation requires covering the opening with the cleanest material available to prevent atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential for infection. Placing the client in the supine position is useless and will impair further the client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is taken to obtain the occlusive dressing.

An 82-year-old client is scheduled for physical therapy after a fracture of the arm. Considering the older population, the nurse recalls that mild exercise is likely to have which effect on the client's respirations?

Increase to 24 breaths per minute - In an older client, respirations are expected to increase to 24 breaths per minute and are a response to the need for oxygen at the cellular level because of the increased metabolic rate associated with exercise. Respirations that become progressively more difficult should not occur with mild exercise unless the client has cardiac disease. The rate of respirations will increase with mild exercise; because of inflexibility of the chest in the older adult, the depth will increase only minimally. Irregular respirations are not an expected response to exercise; this indicates a problem.

When caring for a client who is receiving mechanical ventilation through an endotracheal tube, which collaborative action would the nurse anticipate when the client's partial pressure of end-tidal carbon dioxide (PETCO2) is 60 mm Hg?

Increase respiratory rate setting. - Normal PETCO2 ranges from 20 to 40 mm Hg. A value of 60 mm Hg is high and indicates hypoventilation, which would be corrected with an increase in respiratory rate. Because the client is hypoventilating, extubation would not be planned yet. There is no indication that the client is hypoxemic. Administration of sedative medications would further decrease the respiratory rate.

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula - Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. Endotracheal intubation is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is not the priority intervention and requires a prescription.

Which collaborative action would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.24, PaCO2 60 mm Hg (7.98 kPa), HCO3 20 mEq/L (20 mmol/L), PaO2 54 mm Hg (7.18 kPa), and O2 saturation 88% (0.88)?

Intubation and mechanical ventilation - The client's low pH, high PaCO2, low HCO3, low PaO2, and low oxygen saturation indicate respiratory failure and the need for mechanical ventilation. The client has respiratory acidosis due to poor ventilation and CO2 retention and lactic (metabolic) acidosis secondary to hypoxemia. Oxygen at 6 L/minute will not be adequate to resolve hypoxemia. Nebulized albuterol would improve ventilation, but not enough to resolve the respiratory acidosis. Sodium bicarbonate would help correct pH and HCO3, but would not correct hypoxemia.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?

Respiratory acidosis - The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2, and the acceptable range of arterial Pco2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.