nurs 327
The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.)
Apply an ice collar. Stay on bed rest during the febrile stage of the illness. Try a liquid or soft diet during the acute stage of the disease.
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
bilateral lower lobes
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?
edema of the upper airway
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
hoarseness for 2 weeks
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.
hoarseness of more than 2 week's duration
You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing?
how these issues affect the client's quality of life
Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?
hyperbaric
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
lying on the unaffected side
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
noisy breathing
Which oxygen administration device has the advantage of providing a high oxygen concentration?
nonrebreathing mask
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
palpates the thyroid cartilage
The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to
purse the lips when exhaling air from the lungs.
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
regular breathing where the rate and depth increase, then decrease
A client is described as having pectus carinatum. What would be the physical manifestation of this condition?
the sternum protrudes and the ribs are sloped backward
What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration?
20-25 mm Hg
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?
oxygen saturation of 90%
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it."
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
"I was chewing ice chips all day long."
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.
"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?
20 mL or less
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
463 and humidify inspired air
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5-20 minutes
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.
Diaphragm contracts and elongates the chest cavity.
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Localized calf tenderness
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
Which is a deformity of the chest that occurs as a result of overinflation of the lungs?
barrel chest
A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
tonsils
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
total laryngectomy
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
venturi mask
The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?
vesicular
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
volume-controlled
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
"Family members should continue to talk to the client."
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
"do not smoke and avoid being around others who are smoking."
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
PaCO2
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.
Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Monitor pulmonary status as directed and needed.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
The nursing assistant is pouring a glass of water to wet the client's mouth.
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)?
Vital capacity of 3,000 mL
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?
chest tube drainage, 190 mL/hr
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
endotracheal suctioning
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
ineffective airway clearance related to excess mucus production
Select the nursing diagnosis that would warrant immediate health care provider notification.
ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation
What is the primary function of the larynx?
producing sound
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
sudden restlessness
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
water-seal chamber
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?
wheezes
The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?
evidence of muscle weakness
The clinical finding of pink, frothy sputum may be an indication of which condition?
pulmonary edema
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is
amoxicillin-clavulanic acid
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
auscultate lung sounds
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
inspecting the roof of the nasopharynx
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
measuring and documenting the drainage in the collection chamber
In which position should the client be placed for a thoracentesis?
sitting on the edge of the bed
A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which information from the client would necessitate the nurse to obtain a new specimen?
"I coughed that up about 8 hours ago"
The nursing instructor is teaching students about the respiratory system. The instructor knows the teaching has been effective when a student makes which statement?
"Ventilation is the movement of air in and out of the respiratory tract."
A client undergoes a laryngectomy to treat laryngeal cancer. What instruction should the nurse include in the teaching about the neck stoma?
"keep the stoma moist"
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?
"the ET tube will maintain your airway while you're under anesthesia."
A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply.
Decreased elasticity of the alveolar sacs Increased residual volume Increased diameter of alveolar ducts Increased thickness of alveolar sacs
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?
Partial laryngectomy
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.
To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?
a bottle of sterile water
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
a client experiencing hypothermia
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?
a feeling of swelling at the back of the throat
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem.
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?
an antiviral agent such as acyclovir
A client has a sucking stab wound to the chest. Which action should the nurse take first?
apply a dressing over the wound and tape it on three sides
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
assist control
For a client with an endotracheal (ET) tube, which nursing action is the most important?
auscultating the lungs for bilateral breath sounds
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
A late complication of radiation therapy is
laryngeal necrosis
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?
places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
In relation to the structure of the larynx, which describes the cricoid cartilage?
the only complete cartilaginous ring in the larynx
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
when the patient has less than 30 mL for 2 consecutive days
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply.
The cuff is deflated before the tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about?
absent distal pulses
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?
an infection with pneumococcal pneumonia
Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?
blood pressure increase of 20 mm Hg
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
circulatory hypoxia
A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:
fever
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
fluoroscopy
A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?
frontal
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include
hoarseness
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
no longer than 10 seconds
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for
nuchal rigidity
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
partial pressure of arterial oxygen (PaO2)
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?
95%
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
anterior surface of the right side of the chest, between the fourth and fifth rib
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
auscultate the lung for adventitious sounds
What assessment method would the nurse use to determine the areas of the lungs that need draining?
auscultation
Solu-medrol and prednisone are glucocortico steroids used to prevent or control inflammation in the lungs and airways. As such, which lab value would take priority in the coordination of care for a patient receiving this therapy?
bedside blood glucose reading of 388 mg/ dL
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
cyanosis
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
impaired gas exchange
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?
lungs are clear on auscultation
Pink, frothy sputum may be an indication of
pulmonary edema
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to:
remove air from the pleural space
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client
returning to the nursing unit with two chest tubes
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?
rhonchi
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?
applying nasal packing
Which is a potential complication of a low pressure in the endotracheal tube cuff?
aspiration pneumonia
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?
cancer
What finding by the nurse may indicate that the client has chronic hypoxia?
clubbing of the fingers
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
continues assessing the client's respiratory status frequently
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
crackles
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?
deviation from the midline
You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?
edema of the upper airway
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
seek medical help if he experiences inability to swallow
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse
assesses the client's tracheostomy and lung sounds every 15 minutes
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing
Which is the priority nursing diagnosis for a client undergoing a laryngectomy?
ineffective airway clearance
A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?
pulmonary embolism
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?
Streptococcus pneumoniae
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?
apply direct continuous pressure
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?
asthma
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?
continuous positive airway pressure (cpap)
After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
effective breathing at a rate of 16 breaths/minute through the established airway
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?
emphysema
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?
encourage coughing to mobilize secretions
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
encourage the patient to take approximately 10 breaths per hour, while awake
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
ensure mouth breathing
A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?
ethmoid
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
i will breathe in through my mouth and out through my nose
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
impaired gas exchange
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?
impaired gas exchange related to ventilator setting adjustments
Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation?
inspiratory reserve volume
The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a client with a respiratory disorder in a way that
manages decreased energy levels.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
manual resuscitation bag
A Black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
oxygen toxicity
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?
pulse oximetry
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
reduced cardiac output
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
they help prevent cardiac arrhythmias
You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?
they respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:
take prescribed albuterol (Ventolin) before performing postural drainage.
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
dull
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
routinely deflating the cuff
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
runs of ventricular tachycardia
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first
stands behind the worker, who has hands across the neck
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
suction the client's artificial airway
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?
suction the client, withdraw residual air from the cuff, and reinflate it
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
swallow reflex
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
symmetry of the client's chest expansion
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV)
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
take deep breaths and cough forcefully
A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?
the client has a funnel chest
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
the patient is hypoxic from suctioning
A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?
the patient will have an insertion of a tracheostomy tube
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
the system has an air leak
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
the two methods of perfusion are the bronchial and pulmonary circulation
