Pulmonary

The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. What information should be included in the plan? Select all that apply.

Splint or support the incision to promote maximal comfort. Inhale slowly through the nostrils; exhale through pursed lips. Hold the breath for about 5 seconds to expand the alveoli. Repeat this breathing method 5 to 10 times hourly.

A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions. When planning this client's care, the nurse should include which intervention?

Teaching the client how to deep-breathe and cough

A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding?

The lung has fully expanded.

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.

Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination?

a 75-year-old woman with diabetes

A physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by

checking and taping all connections.

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations?

nonrebreather mask

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first?

impaired gas exchange

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?

Acute respiratory distress syndrome (ARDS).

The nurse is reviewing the history and physical and health care provider prescriptions on the medical record of a newly admitted client. What should the nurse do first?

Initiate airborne precautions.

A nurse is caring for a client following a thoracotomy. A physical assessment reveals the client has incisional pain, a poor cough effort, and scattered rhonchi throughout all lung fields bilaterally. Which action should the nurse take first?

Medicate the client with prescribed morphine.

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate?

Placing the client in high Fowler's position

Following a thoracotomy, the client has pain of 9 on a 10-point scale. What should the nurse do thirty minutes after administering the highest dose of the prescribed pain medication?

Reassess the client.

A middle-aged client who has smoked two packs of cigarettes for the last 10 years is admitted with a diagnosis of lung cancer. The client reports having "no appetite" and exhibits symptoms of anorexia. The client is 5 feet, 8 inches (173 cm) tall and weighs 112 lb (50.8 kg). The client is now scheduled for a left lung lobectomy. The nurse should include which factor when planning to prevent postoperative pulmonary complications?

The client's weight relative to height is low.

The nurse is taking a nursing history from a client prior to surgery. Which information in the client's history would have a significant impact on the client's recovery postoperatively? The client:

has smoked 1 pack of cigarettes a day for 12 years.

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

hypoxia not responsive to oxygen therapy

Which mental status change may occur when a client with pneumonia is first experiencing hypoxia?

irritability

A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?

Instruct the client to take a deep breath and hold it.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply.

Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Ensure all connections are securely taped.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

runs of ventricular tachycardia

The health care provider prescribed intravenous naloxone to reverse the respiratory depression from morphine administration. After administration of the naloxone, what should the nurse do?

Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.

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.

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? Steroids will:

have an anti-inflammatory effect.

A client who has been recently extubated has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP?

hemoglobin and hematocrit

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

hypotension

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

placing the client in respiratory isolation

The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. What should the nurse do next?

Allow the client to rest for a few minutes, then re-assess.

Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first?

Explain the risks of not expanding the lungs and why the exercise is important.

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require

a chest X-ray.

A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that they should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is

1.4 L.

While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?

Mark the area with a skin pencil at the outer periphery of the crackling.

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.

Which complication is associated with mechanical ventilation?

gastrointestinal hemorrhage

The nurse is caring for an older adult who has been bedridden for an extended period. Which symptom indicates that the client has hypoxia?

confusion

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

use of accessory muscles

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy?

The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

The nurse is suctioning a client's tracheobronchial tree. Identify the area to which the nurse should advance the catheter.

at the fork in the lungs

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultating the lungs for bilateral breath sounds

A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching?

diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. The client reports shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.

A client with acute respiratory distress syndrome is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the Po2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP). What recommendation should the nurse give to the HCP?

initiating IV sedation.

The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed?

petrolatum gauze

After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when noting which findings? Select all that apply.

Fluctuations in the water-seal chamber occur when the client breathes. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber.

A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy.

When providing oral hygiene for an unconscious client, the nurse must perform which action?

Place the client in a side-lying position.

Which consideration is the most important when performing tracheotomy suctioning?

The client should be hyperoxygenated, then suctioned for 10 to 15 seconds.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make?

`The client is severely hypoxic.

A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. What should the nurse further assess?

a pneumothorax

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent

aspiration.

When assessing a client with a chest tube inserted for a hemothorax, the nurse would expect which findings? Select all that apply.

fluid drainage into the first chamber of the drainage system a dry dressing at the chest wall insertion site tidaling in the water-seal chamber during respirations

The nurse is planning care for a client with a crushing chest injury. The client is in an intensive care unit, and the client's vital signs have not stabilized. Which finding puts the client at risk for acute respiratory distress syndrome (ARDS)?

hypovolemia

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

partial pressure of arterial oxygen (PaO2) of 69 mm Hg

A client is undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply.

pneumothorax subcutaneous emphysema tension pneumothorax pulmonary edema

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply.

respiratory rate of 12 to 20 breaths per minute breath sounds present and equal in all lobes oxygen saturation on room air is 95%.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered.

What should the nurse do to help a client prevent atelectasis and pneumonia after surgery?

Offer pain medication before having the client deep-breathe and use incentive spirometry.

A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?

respiratory acidosis

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition?

respiratory acidosis

The nurse is caring for a client following surgery. Which nursing action does not aid in meeting the postoperative goal of clear breath sounds?

providing a minimum of 1,000 mL of fluid per day

After a lobectomy for lung cancer, the nurse instructs the client to perform deep breathing exercises. What is the expected outcome of these exercises?

Expand the alveoli and increase lung surface available for ventilation.

A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about?

heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24

Which sign is an early indicator of hypoxia in the unconscious client?

restlessness

A nurse working in the emergency department receives arterial blood gas results on four clients. Which laboratory result requires immediate nursing intervention?

pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

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?

acute respiratory distress syndrome (ARDS)

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

depriving the client of sufficient oxygen supply.

A client with suspected lung cancer is undergoing a thoracentesis. Which outcomes of the procedure are expected? Select all that apply.

diagnosis of underlying disease palliation of symptoms relief of acute respiratory distress

A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?

fighting the ventilator

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

oxygen saturation of 90%

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer

vitamin K1 (phytonadione).

The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms? Select all that apply.

fever use of accessory muscles during respiration crackles or rhonchi

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line

A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:

a tension pneumothorax.

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 nurse is completing annual cardiopulmonary resuscitation training. The class instructor states that a client has fallen off a ladder and is lying on the back. The client is unconscious and not breathing. What technique should the nurse use to open the client's airway?

jaw-thrust

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

kinking of the ventilator tubing

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

light-headedness or paresthesia

Which item must the nurse consider when positioning a client for tracheal suctioning?

Position in a semi-Fowler's position.

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?

airborne precautions

A client's chest tube accidentally disconnects from the drainage tube. The nurse should first:

clamp the chest tube.

A client is postoperative following resection of a lower lobe of the lung and presents with a large amount of respiratory secretions. The nurse should include which actions during care? Select all that apply.

turning and positioning every 2 hours administering bronchodilators providing oxygen via humidified mask

A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse?

4 hours

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which other client?

60-year-old client admitted for investigation of transient ischemic attacks.

The nurse has assisted the health care provider at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. What should the nurse do next?

Assess breath sounds.

A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next?

Assess the client for pain and medicate as appropriate.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first?

Assist the client to take several deep breaths and cough.

A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. What should the nurse do first?

Attempt reinsertion of tracheostomy tube.

The nurse is repositioning a client with a chest tube in bed when the chest tube accidentally becomes disconnected from the chest tube container. What is the nurse's priority action at this time?

Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing.

A client has a chest tube attached to suction. Which interventions would the nurse perform? Select all that apply.

Change the dressing as ordered using aseptic technique. Palpate the surrounding area of the chest tube for crepitus. Mark the amount of drainage in the chamber at the end of the shift.

A nurse is instructing a client on how to use an incentive spirometer. The nurse should instruct the client to use the spirometer using steps. Place the steps in order from first to last. All options must be used.

Instruct the client to client exhale fully. Instruct the client to inhale on the mouthpiece and hold the breath for 3 seconds. Instruct the client to passively exhale. Instruct the client to take a deep breath and cough.

When assessing a client diagnosed with pneumonia, the nurse auscultates crackles. Which is the best action?

Document the findings as the only action.

A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which actions? Select all that apply.

Elevate head of bed to 90 degrees. Administer diuretics as ordered.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees.

The nurse is assessing a client newly transferred from the recovery room and notes a low-grade temperature, tachycardia, tachypnea, and crackles. Which action is the nurse's priority?

Encourage client to cough and take a deep breath.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?

Further assess the client for reinflation of the lung.

A female client diagnosed with lung cancer is to have a left lower lobectomy. The nurse should assess the client for which factor that increases the client's risk of developing postoperative pulmonary complications?

Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg).

A client is transported to the emergency department with an acute respiratory infection. Vital signs are T 102 degrees F (38.8 degrees C), P 110 bpm, R 32 breaths/min. Circumoral cyanosis is noted, and the oxygen saturation is 86%. What should be the immediate actions by the nurse caring for this client? Select all that apply.

Initiate oxygen at 6 L/min via nasal cannula. Place the client in high Fowler's position.

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?

Make sure that the drainage apparatus is always below the client's chest level.

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure). The nursing policy manual recommends use of the gauze pad. What should the nurse do?

Make sure the gauze pad is dry and the client is in a comfortable position.

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used.

Open the airway. Start an IV access site. Call the health care provider (HCP). Explain the situation to the family.

A client with heart failure develops pink, frothy sputum and restlessness. Which actions are the priority for the nurse? Select all that apply.

Place the client in high Fowler's position. Notify the physician of the client's change in status. Auscultate bilateral lung sounds for crackles.

A client has been diagnosed with deep vein thrombosis (DVT). Suddenly, the client develops chest pain and severe dyspnea. Which priority actions should be taken by the nurse? Select all that apply.

Position in Fowler's position, initiate oxygen, and notify the physician Auscultate for abnormal breath sounds and encourage deep breathing Assess vital signs and obtain oxygen saturation

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/l). The nurse determines that which of the following is a possible cause for these findings?

Pulmonary embolus.

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used.

Splint the incisional site. Inhale through the nose. Exhale through pursed lips. Cough deeply from the lungs

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax?

Sudden, sharp pain on the affected side.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.

The SpO2 and PO2 have decreased. The client is tachycardic with drop in blood pressure. The face has increased skin breakdown and edema.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?

The alveoli expand and increase the lung surface available for ventilation.

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 hyper oxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

Which choice demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?

Use sterile gloves during the procedure.

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance?

breath sounds clear on auscultation

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

extreme anxiety

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first?

client experiencing tracheal deviation following a subclavian catheter insertion

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

reduced cardiac output

A client comes to the emergency department with status asthmaticus. The client's respiratory rate is 48 breaths/minute, and the client is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3--) of 26 mEq/L. What disorder is indicated by these findings?

respiratory alkalosis

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply.

Monitor serum creatinine and blood urea nitrogen levels. Administer humidified oxygen. Auscultate the lungs.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

encouraging increased fluid intake