NCLEX Respiratory

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

"Blocked nasal passages impair the sense of smell."

The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?

"I should perform arm exercises 2 or 3 times a day." Rationale: The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the primary health care provider if these symptoms occur.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?

"I should use diluted alcohol on the stoma to clean it." Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement?

"I will discard used tissues in a plastic bag."

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful?

"My nails may become clubbed."

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply.

1.Anosmia ( loss of smell) 2.Chronic cough 3.Purulent nasal discharge. Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and strong aromas are not characteristics.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply.

1.Dyspnea at rest 2.Clubbed fingers 3.Muscle retractions 6.Prolonged expiratory breathing phase Rationale: The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.

The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply.

1.Fatigue 2.Lethargy 4.Morning cough 5.Low-grade fever Rationale: The symptoms of tuberculosis include a slight morning cough, fatigue, lethargy, and low-grade fever. The other symptoms listed are advanced (not initial) signs and symptoms.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?

Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly. Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process?

Diffusion

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The primary health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction?

Hold the gum between the cheek and teeth periodically. Rationale: Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink should be avoided 15 minutes before and during use.

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position?

Semi-Fowler's Rationale: After any procedure involving lung surgery, the nurse should position the client in semi-Fowler's position.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

A client tells the nurse that the primary health care provider (PHCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder?

The client has reduced lung volume and fibrosis on chest x-ray.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

This is expected, and the client should gradually increase activity as tolerated.

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments?

"I cannot give Legionnaires' disease to other people."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

"I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain?

"It hurts more when I breathe in." Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration.

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching?

"It will keep the small airways open."

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

"That isn't done because people often would develop pneumonia from the constricting effect on the lungs."

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply.

1.Fatigue 2.Malaise 3.Anorexia Rationale: Silicosis is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli leading to fibrosis. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

1.Sitting up and leaning on a table 2.Standing and leaning against a wall 4.Sitting up with the elbows resting on knees

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply.

2.Cigarette smoking 3.Genetic risk factor 4.Environmental factors 6.Alpha-1 antitrypsin (AAT) deficiency Rationale: Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

Which are possible causes of upper airway obstruction? Select all that apply.

2.Laryngeal edema 3.Head and neck cancer 4.Foreign body aspiration 5.Lymph node enlargement

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply.

2.Teach diaphragmatic and pursed-lip breathing. 3.Encourage alternating activity with rest periods. 4.Teach the client techniques of chest physiotherapy. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long?

48 to 72 hours

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism?

A 73-year-old woman who has just had pinning of a hip fracture

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

A shunt unit exists.

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

Accumulation of pleural fluid in the inflamed area

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing?

Administer the prescribed bronchodilator. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high-Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the primary health care provider?

Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?

Contact the primary health care provider (PHCP).

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

Dyspnea Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism?

Dyspnea Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?

Eat foods that are highly seasoned in moderation. Rationale: Foods that are highly seasoned are irritating to the throat and should be completely avoided. The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority?

Inability to clear the airway related to inability to expectorate sputum

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

The nurse and an assistive personnel (AP) are assisting the respiratory therapist to position a client for postural drainage. The AP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas?

Lobes

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client?

Low arterial PaO2. Rationale: The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning?

Lying on the back in a low-Fowler's position

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action?

Moves downward and out

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration

The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

Provide nontracheal suctioning as needed to remove secretions.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time?

Several weeks to months Rationale: The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make?

The client's test result will be positive, and a chest x-ray study will be required for evaluation.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder?

The inflamed pleurae cannot glide against each other as they normally do.

A client who is experiencing respiratory difficulty asks the nurse, "Why is it so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

The respiratory muscles relax.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?

Tripod position

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition?

Opening of small airways that contain fluid.

The nurse is providing immediate postprocedural care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed?

"I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung re expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply.

1. Dry air 2. Exercise 5.An upper respiratory infection (URI) 6.Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale: Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

1.Activities should be resumed gradually. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary, because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply.

1.Clamp 4.Vaseline gauze 6.Suction equipment

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply.

1.Cough 2.Dyspnea 5.Chills and night sweats Rationale: The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

1.Dyspnea 3.Night sweats 4.A bloody, productive cough 5.A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

A clinic nurse notes that large numbers of clients present with flu-like symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply.

1.Get plenty of rest. 2.Increase intake of liquids. 3.Take antipyretics for fever. 5.Eat fruits and vegetables high in vitamin C. Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

The nurse is providing preoperative teaching to the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply.

1.Sit upright in the bed or in a chair. 4.Place the mouthpiece in your mouth and seal your lips tightly around it. 5.After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Rationale: For optimal lung expansion with an incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position while holding the incentive spirometer in an upright position. The mouthpiece should be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.

1.Suctioning the client as needed 2.Encouraging coughing every 2 hours 4.Supporting the neck incision when the client coughs 5.Monitoring the respiratory status frequently as prescribed

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

2.A hyperinflated chest noted on the chest x-ray. 3.Decreased oxygen saturation with mild exercise. Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection to remove a cancerous tumor. Which are the expected assessment findings? Select all that apply.

3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the primary health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis?

A man who is an inspector for the U.S. Postal Service. Rationale: Clients at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus infection or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding?

Absence of dyspnea Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The primary health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse is performing a respiratory assessment on a client with a left lower lobe lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds. The nurse would interpret this as which sound?

Bronchial breath sounds Rationale: The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like 2 rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

Collapse of alveoli and decreased compliance

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The primary health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect?

Collapse of alveoli and decreased compliance. Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Viral infection may be 1 reason a client develops atelectasis. The remaining options are incorrect.

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note?

Complaints of night sweats Rationale: The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

Encouraging active range-of-motion exercises

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?

Exposure to tuberculosis

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

Flushing Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse should document this finding as which sound?

High-pitched wheezes Rationale: The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client?

Hyperinflation of lungs documented by chest x-ray. Rationale: The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed?

I have to keep my nasal cannula oxygen levels between 4 and 6 L/min." Rationale: Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per primary health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate. Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside?

Intubation tray

The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease?

It can be caused by the inhalation of spores from bird droppings.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

Lung crackles in the remaining lung. Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing?

Lying on the back in a low-Fowler's position

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm?

Moves downward and out as it contracts

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result?

Negative Rationale: A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. The remaining options are incorrect interpretations.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem?

Pleural pain and fever. Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area?

Pleural space

An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition?

Pleurisy Rationale: The sound that the nurse hears is a pleural friction rub. A pleural friction rub is the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is a superficial, low-pitched, coarse rubbing or grating sound that sounds like 2 rough surfaces rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface. It is not cleared by a cough. Disorders that cause airflow obstruction, such as emphysema or asthma, would produce high- or low-pitched wheezes (musical sounds similar to a squeak). Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive Rationale: The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?

Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

Rapid, shallow respirations. Rationale: An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

Sputum culture. Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

A client is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse should document this finding as which sound?

Stridor Rationale: The sound that the nurse hears is stridor. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. The nurse immediately notifies the primary health care provider (PHCP). The nurse also places the client in a high-Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy. Rhonchi (low-pitched, coarse, loud, low-snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. High-pitched wheezes are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly?

The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How should the nurse interpret this finding?

There is an air leak somewhere in the system. Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.