NUR2243 Respiratory EAQs

A chest tube with an attached closed-drainage system is inserted into a client who was stabbed in the chest. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber.

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment?

Ventilatory exchange

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response?

"You seem concerned about your diagnosis."

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

An obese client with leg trauma

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention?

Place client in a high-Fowler position

What is the normal value of inspiratory reserve volume?

3.0 L

A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response?

Depression in the respiratory center

The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?

Night sweats and blood-tinged sputum

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus?

pink

A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system?

respiratory

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit?

tachycardia

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Restlessness

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action by the nurse is the first line of defense against an emerging influenza pandemic?

Reporting surveillance findings to appropriate public health officials

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary, and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning.

Assess client's vital signs and lung sounds Activate the ventilator suction hyperoxygenation setting Insert the catheter without applying suction Rotate the catheter while suction is applied

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

Check the tube to ensure that it is not kinked.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding?

Subcutaneous emphysema

After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response?

"Tube feedings promote healing by reducing the risk for infection."

To prevent potential aspiration, what technique should a nurse use when cleaning a tracheostomy tube that has a non-disposable inner cannula?

Apply precutdressing around the insertion site with the flaps pointing upward.

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason?

Difficulty in expelling the air trapped in the alveoli

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do first?

Inspect the catheter

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. What is the priority nursing intervention?

Notify the healthcare provider immediately

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP)

When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider?

Severe shortness of breath

A client who is negative for human immunodeficiency virus (HIV) but who has a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding?

The client has been exposed to the pathogen that causes tuberculosis.

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client?

The tracheostomy tube interferes with effective coughing.

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?

Turning and positioning

A nurse is caring for a client in respiratory distress. The healthcare provider prescribes oxygen via a nonrebreather mask. Which mask should the nurse use to implement the oxygen prescription?

with bag attached

The nurse is teaching a nursing student about the use of magnetic resonance imaging (MRIs). Which statement of the nursing student indicates effective learning?

"Clients with claustrophobia can have an MRI."

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. What assessment by the nurse most readily detects this complication?

Palpating the neck or face

What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder?

1. Inspect the mouth. Observe the rise and fall of the soft palate. Assess the symmetry of enlarged tonsils, if present. Inspect the neck symmetry. Palpate the lymph nodes.

A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern?

Asphyxia

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages.

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on?

Having the client breathe into a paper bag

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?

Mark the time and fluid level on the side of the drainage chamber

What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord?

Tracheostomy set and oxygen

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. What should the nurse do?

Assess for obstructions in the chest tube

After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the nurse do?

Check the system for air leaks

Which condition can cause a client's partial pressure of end-tidal carbon dioxide (PETCO2) to be 50 mmHg?

Hypoventilation

A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during swallowing. Which statement of the client indicates the need for further teaching?

"I should drink more water and other thin liquids."

A client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statements by the client indicates that the nurse should follow up? Select all that apply.

"My urine may become discolored." "I will lose weight while on this medication." "The medication should be taken between meals." "When I'm feeling better, I can stop taking this medication."

Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" Which is the nurse's best response?

"You seem very concerned. Tell me what you know about your surgery."

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%?

Nonrebreather mask

A nurse is notified that a victim of a gunshot wound to the right side of the chest is being transported to the emergency department. To prepare for the client, what is the priority nursing intervention?

Obtaining equipment for chest tube insertion

A client who was discharged from the hospital after a rhinoplasty for a fractured nose complains of nasal bleeding. Which activity of the client might have led to this condition?

Performing Valsalva maneuvers

While examining a client's respiratory system, a nurse auscultates the client's lung and hears these sounds. What should the nurse document in the client's medical record?

Vesicular breath sounds Vesicular breath sounds are normal, low-pitched rustling sounds heard over peripheral lung fields. Fine crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Coarse crackles are lower-pitched, rattling sounds caused by fluid or secretions in large airways. These are abnormal breath sounds associated with bronchitis or pneumonia. Bronchial breath sounds are normal, harsh, hollow, tubular, blowing sounds heard over the trachea and larynx.

The nurse is teaching a student nurse about the preventive measures to be taken to prevent injury in clients who are receiving anticoagulant therapy. Which statement indicates the need for further teaching?

"I will assess intravenous sites at least every 6 hours for bleeding."

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do?

Increase fluid intake to at least 2 L a day