PrepU: Respiratory
A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause nasal congestion. nervousness. lethargy. hyperkalemia.
Correct response: nervousness. Explanation: Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps. Remediation: Albuterol Sulfate
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? respiratory acidosis respiratory alkalosis metabolic alkalosis metabolic acidosis
Correct response: respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis. Remediation: Respiratory Acidosis
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? Avoid contact with fur-bearing animals. Change filters on heating and air conditioning units frequently. Take ordered medications as scheduled. Avoid goose down pillows.
Correct response: Take ordered medications as scheduled. Explanation: Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks. Remediation: Asthma Respiratory: Asthma
A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis
Correct response: respiratory acidosis Explanation: An increased level of dissolved carbon dioxide (PaCO2) indicates respiratory acidosis. Metabolic acidosis and alkalosis are not correct because this is a respiratory issue, not a metabolic one. Respiratory alkalosis would have a PaCO2 deficit, not an increase. Remediation: Blood Gas Analysis And Co-Oximetry, Respiratory Therapy
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say "I need to keep my inhaler at the bedside." "I should eat a high-protein diet." "I should become involved in a weight loss program." "I should sleep on my side all night long."
Correct response: "I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea. Remediation: Obesity Apnea
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? A positive reaction indicates that the client has active tuberculosis (TB). A positive reaction indicates that the client has been exposed to the disease. A negative reaction always excludes the diagnosis of TB. The PPD can be read within 12 hours after the injection.
Correct response: A positive reaction indicates that the client has been exposed to the disease. Explanation: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease. Remediation: Tuberculin Skin Testing Tuberculin Skin Tests
Which measure should the nurse perform when suctioning a tracheostomy tube? Apply suction while inserting the suction catheter into the tube. Change the tracheostomy tube after suctioning the client. Select a suction catheter that approximates the diameter of the tracheostomy tube. Administer high concentrations of oxygen before suctioning the client.
Correct response: Administer high concentrations of oxygen before suctioning the client. Explanation: Clients are hyperoxygenated before suctioning to prevent hypoxia.Suction is never applied while inserting the catheter into the airway.Laryngectomy tubes are not changed after suctioning.The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure. Remediation: Tracheostomy Suctioning, Pediatric
A client with chronic renal failure is being admitted with pulmonary edema. Which is the priority nursing intervention? Monitor serum potassium levels. Assess lung sounds and oxygen saturation level. Obtain daily weight. Record accurate intake and output.
Correct response: Assess lung sounds and oxygen saturation level. Explanation: A client with chronic renal failure who is admitted with pulmonary edema should have their lungs monitored as the priority. The client could have hyperkalemia, hypertension, or anemia, and these assessments should be completed as well. Recording accurate intake and output and monitoring daily weight would also be appropriate. However, respiratory status is the priority. Remediation: Kidney Disease (Chronic) Respiratory: Change In Breathing Sounds
A nurse is caring for a client following an elective bronchoscopy. Which intervention by the nurse is most appropriate? Elevate the head of the bed to a high Fowler's position. Do not give the client anything by mouth until the gag reflex returns. Apply oxygen 2 L via nasal cannula for at least 4 hours after bronchoscopy. Supply the client with ice chips to sooth a sore throat.
Correct response: Do not give the client anything by mouth until the gag reflex returns. Explanation: Assessing the risk for aspiration and maintaining an open airway is the priority. As a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the client to take oral fluids or food. Remediation: Bronchoscopy
A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system? Verify that the air vent on the water-seal drainage system is capped when the suction is off. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. Ensure that the chest tube is clamped when moving the client out of the bed. Make sure that the drainage apparatus is always below the client's chest level.
Correct response: Make sure that the drainage apparatus is always below the client's chest level. Explanation: The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended. Remediation: Chest Tube Drainage System Monitoring And Care
What instruction should the nurse give the client who underwent a laryngectomy and is now going home? Perform mouth care every morning and evening. Provide adequate humidity in the home. Maintain a soft, bland diet. Limit physical activity to shoulder and neck exercises.
Correct response: Provide adequate humidity in the home. Explanation: Adequate humidity should be provided in the home to help keep secretions moist. A bedside humidifier is recommended. A high fluid intake is also important to liquefy secretions. Mouth care is important to prevent drying of mucous membranes and should be performed frequently throughout the day, especially before and after meals, to help stimulate appetite. The client may eat any food that can be chewed and swallowed comfortably. The client may resume physical activity as tolerated. Remediation: Laryngectomy
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? Avoid contact with fur-bearing animals. Change filters on heating and air conditioning units frequently. Take ordered medications as scheduled. Avoid goose down pillows.
Correct response: Take ordered medications as scheduled. Explanation: Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks. Remediation: Asthma Respiratory: Asthma
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client exhibits bronchial breath sounds over the affected area.
Correct response: The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation. Remediation: Arterial Blood Gas Analysis Respiratory: Oxygen Transport
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows to monitor closely for complications that include which of the following? bilateral wheezes bronchial asthma acute respiratory distress syndrome (ARDS) renal failure
Correct response: acute respiratory distress syndrome (ARDS) Explanation: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. ARDS refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation. Remediation: Acute Respiratory Distress Syndrome
An older adult client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? age osteoarthritis vegetarian diet daily bathing
Correct response: age Explanation: The client's age is a predisposing factor for pneumonia; pneumonia is more common in older or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia. Remediation: Pneumonia
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion? respirations unlabored hollow sound on chest percussion decreased mucus production breath sounds clear on auscultation
Correct response: breath sounds clear on auscultation Explanation: Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production.
A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should: collaborate with the social worker to investigate possible availability of funds. contact the community's free clinic for medications. call the public health nurse to research free medications. coordinate with the pharmaceutical company for free samples.
Correct response: collaborate with the social worker to investigate possible availability of funds. Explanation: The nurse should collaborate with the social worker about the client's financial concerns. This collaboration can be done independently without a physician's order. The physician must notify the public health department of the client's diagnosis, but a public health worker does not get involved with the client's financial concerns. The physician and home health nurse are not typically involved with the client's financial concerns until after the client is discharged.
A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose? leg movement finger movement lip movement fighting the ventilator
Correct response: fighting the ventilator Explanation: Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so the client breathes in synchrony with the ventilator. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer a dose I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn't used to determine the need for another dose. Remediation: Pancuronium Bromide
The nurse is aware that the best position for a client with impaired gas exchange is what? side-lying high Fowler's Sims semi-Fowler's
Correct response: high Fowler's Explanation: For a client with impaired gas exchange, high Fowler's position is the best position because it allows maximal chest expansion. If the client cannot tolerate high Fowler's position, semi-Fowler's is the next best choice, because it increases comfort and allows for chest expansion. The lateral decubitus and supine positions do not promote chest expansion. Sims position is recommended for perineal inspection. Remediation: Impaired Gas Exchange Respiratory: Gas Exchange In Alveoli
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: increased forced expiratory volume. normal breath sounds. inspiratory and expiratory wheezing. morning headaches.
Correct response: inspiratory and expiratory wheezing. Explanation: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia. Remediation: Asthma Respiratory: Asthma
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately? leukocytosis anemia low hemoglobin level normal erythrocyte sedimentation rate
Correct response: leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. This finding is expected in a client with rheumatic fever. Laboratory data indicating anemia or a low hemoglobin level will need to be addressed but are not critical and associated with the current disease process. A marginal erythrocyte sedimentation rate would be communicated on the laboratory report. Remediation: Pharyngitis
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis
Correct response: metabolic acidosis Explanation: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis. Remediation: Arterial Puncture For Blood Gas Analysis
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH bicarbonate (HCO3-) partial pressure of arterial oxygen (PaO2) partial pressure of arterial carbon dioxide (PaCO2)
Correct response: partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2 Remediation: Arterial Blood Gas Analysis Respiratory: Oxygen Transport
When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings? increased anteroposterior chest diameter underdeveloped neck muscles collapsed neck veins increased chest excursions with respiration
Correct response: partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2 Remediation: Arterial Blood Gas Analysis Respiratory: Oxygen Transport
A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? septicemia pneumonia meningitis pulmonary edema
Correct response: pneumonia Explanation: Pneumonia is the most common complication of influenza. It may be either primary influenza, viral pneumonia, or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza. Remediation: Influenza Haemophilus Influenzae Infection
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? respiratory acidosis metabolic alkalosis respiratory alkalosis metabolic acidosis
Correct response: respiratory acidosis Explanation: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, respiratory acidosis exists and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis. Remediation: Arterial Blood Gas Analysis Respiratory Acidosis
After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? heightened alertness increased heart rate numbness and tingling of the extremities respiratory depression
Correct response: respiratory depression Explanation: Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure. Remediation: Epidural Catheter Insertion, Assisting Epidural Analgesic Administration
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.
Correct response: respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis. Remediation: Arterial Blood Gas Analysis
Metabolic alkalosis (HCO3− retention, acid loss)
pH greater than 7.45 (SI, greater than 7.45) HCO3− greater than 26 mEq/L (SI, greater than 26 mmol/L) PaCO2 greater than 45 mm Hg (SI, greater than 5.3 kPa) Causes: Loss of hydrochloric acid from prolonged vomiting or gastric suctioning Loss of potassium due to increased renal excretion (as in diuretic therapy) or steroid overdose Excessive alkali ingestion Compensation for chronic respiratory acidosis Presention: Slow, shallow breathing Hypertonic muscles Restlessness Twitching Confusion Irritability Apathy Tetany Seizures Coma (if severe)
Respiratory alkalosis (excess CO2 excretion)
pH greater than 7.45 (SI, greater than 7.45) HCO3− less than 22 mEq/L (SI, less than 22 mmol/L), if compensating PaCO2 less than 35 mm Hg (SI, less than 4.7 kPa) Causes: Hyperventilation due to anxiety, pain, or improper ventilator settings Respiratory stimulation caused by drugs, disease, hypoxia, fever, or high room temperature Gram-negative bacteremia Compensation for metabolic acidosis (chronic renal failure) Presentation: Rapid, deep breathing Paresthesia Light-headedness Twitching Anxiety Fear
Respiratory acidosis (excess carbon dioxide [CO2] retention)
pH less than 7.35 (SI, less than 7.35) HCO3− greater than 26 mEq/L (SI, greater than 26 mmol/L), if compensating PaCO2 greater than 45 mm Hg (SI, greater than 5.3 kPa) Causes: Central nervous system depression from drugs, injury, or disease Asphyxia Hypoventilation due to pulmonary, cardiac, musculoskeletal, or neuromuscular disease Obesity Postoperative pain Abdominal distention Presentation: Diaphoresis Headache Tachycardia Confusion Restlessness Apprehension
Metabolic acidosis (HCO3− loss, acid retention)
pH less than 7.35 (SI, less than 7.35) HCO3− less than 22 mEq/L (SI, less than 22 mmol/L) PaCO2 less than 35 mm Hg (SI, less than 4.7 kPa), if compensating Causes: HCO3− depletion due to renal disease, diarrhea, or small-bowel fistulas Excessive production of organic acids due to hepatic disease; endocrine disorders, including diabetes mellitus, hypoxia, shock; and drug intoxication Inadequate excretion of acids due to renal disease Presentation: Rapid, deep breathing Fruity breath Fatigue Headache Lethargy Drowsiness Nausea Vomiting Coma (if severe)
A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 ml. How many milliliters of medication would the nurse pour to administer the correct dose? Record your answer as a whole number.
Correct response: 24 mL Explanation: To calculate drug dosages use the formula: Dose on hand/Quantity on hand = Dose desired/X. Plug in the values for this equation and solve for X:125 mg/5 mL = 600 mg/X.X = 24 mL. Remediation: Safe Medication Administration Practices, General
Which finding in a client diagnosed with asthma would require a nurse to take immediate action? lethargy diaphoresis anhidrosis cough
Correct response: lethargy Explanation: Lethargy can be a manifestation of status asthmaticus. Anhidrosis, cough, and diaphoresis should be further assessed. Remediation: Asthma Respiratory: Asthma
