Respiratory

A nurse is reinforcing teaching to a client who has chronic obstructive pulmonary disorder. Which of the following statements by the client indicates a need for further teaching? 1. "I will rest for at least 30 minutes before eating" 2. "I will take my bronchodilators after meals" 3. "I will eat five or six small meals each day" 4. "I will increase my intake of dietary fiber"

"I will take my bronchodilators after meals"; should be taken before meals to reduce shortness of breath.

A nurse in the ICU is assisting with the care of a client who has acute respiratory distress syndrome and is receiving mechanical ventilation via an endotracheal tube. The provider plans to extubate within the next 24 hours. Which of the following is an important criterion for extubating this client? 1. ability to cough effectively 2. adequate tidal volume without positive pressure 3. no indications of infection 4. no need for supplemental oxygen

Adequate tidal volume without positive pressure; weaning criteria include ability to maintain adequate vital capacity, tidal volume, and minute ventilation without positive pressure or other manually assisted breaths

A nurse is performing pulmonary hygiene for a client with a respiratory infection. The nurse should explain that sitting on the side of the bed helps mobilize secretions from which of the following lung segments? 1. apical segments 2. both upper lobes 3. anterior segments of both lower lobes 4. posterior segments of both lower lobes

Apical segments

The nurse caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following prescribed medications? 1. Carvedilol 2. Fluticasone 3. Captopril 4. Isosorbide dinitrate

Carvedilol; medications that block beta-2 receptors are contraindicated in clients with asthma.

The nurse is caring for a client who has a newly inserted chest tube connected to suction and a water seal drainage system. Which of the following indicates the chest tube is functioning properly? 1. fluctuation of the fluid level within the water seal chamber 2. secretions in the tubing connected to the drainage system 3. bubbling within the water seal chamber 4. equal amounts of secretions in each collection chamber

Fluctuation of the fluid level within the water seal; fluctuation occurs with inspiration and expiration until the client's lungs have re-expanded or the system is occluded.

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postop period? 1. malnourishment r/t NPO status and dysphagia 2. impaired verbal communication r/t tracheostomy 3. high risk for infection r/t surgical incisions 4. ineffective airway clearance r/t thick, copious secretions

Ineffective airway clearance related to thick, copious secretions; a client with a new tracheostomy requires frequent suctioning in the early postop period.

A nurse is caring for a client who has COPD. When contributing to this client's plan of care, the nurse should include which of the following interventions? 1. restrict the client's fluid intake to less than 2 L/day 2. encourage to use upper chest for respiration 3. have client use early-morning hours for exercise and activity 4. instruct client to use pursed-lip breathing

Instruct the client to use pursed-lip breathing; lengthens the expiratory phase of respiration and increases the pressure in the airway during exhalation. Clients who have COPD should breathe from the diaphragm.

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? 1. lethargy 2. high fever 3. edema 4. dry cough

Lethargy; manifestations of pulmonary tuberculosis are lethargy, nausea, fatigue, night sweats, low-grade fever, productive cough, anorexia

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? 1. increase the client's wall suction 2. strip the client's chest tube 3. clamp the client's chest tube 4. reposition the client

Reposition the client; relieves chest burning from the chest tube

A nurse is collecting data from a client who has bronchitis. Which of the following findings should the nurse expect to auscultate? 1. dullness 2. resonance 3. tympany 4. flatness

Resonance; loud, low-pitched sound of long duration

A nurse is caring for a client who is scheduled to undergo thoracentesis. How should the nurse position the client for the procedure? 1. Prone with arms raised over the head 2. sitting, leaning forward over the bedside table 3. supine with head of bed elevated 4. side-lying with knees drawn up to the chest

Sitting, leaning forward over the bedside table; upright position ensures that the diaphragm is dependent and facilitates the removal of accumulated fluid

A nurse is caring for a client who is postop and has developed pneumonia. Which of the following is a possible complication of pneumonia? 1. hemorrhage 2. atelectasis 3. thrombosis 4. edema

Atelectasis; can be caused by retained secretions often associated with pneumonia.

A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following is an appropriate intervention? 1. tilt the head and lift the chin 2. begin the Heimlich maneuver 3. turn the client to the side 4. perform a blind finger sweep

Begin the Heimlich maneuver; should continue until the obstruction is clear or the client loses consciousness

A nurse is reinforcing discharge instructions with the parent of a 6-year-old who just had a tonsillectomy. Which of the following statements by the parent indicates understanding of postop care? 1. "I'll call the doctor if my child is swallowing continuously" 2. "It's okay for my child to have plenty of ice cream" 3. "I'll help my child gargle with salt water a few times a day" 4. "It's alright for my child to ride his bike in a few days"

"I'll call the doctor if my child is swallowing continuously"; frequent swallowing is a sign of hemorrhage following a tonsillectomy. Should avoid coughing, clearing throat, vigorous toothbrushing because they cause bleeding. Activities resumed within 1-2 weeks.

A nurse is caring for a client who sustained multiple injuries related to a motor vehicle crash. When monitoring the client for manifestations of pneumothorax, the nurse should observe for which of the following? 1. inspiratory stridor 2. expiratory wheeze 3. absence of breath sounds 4. coarse crackles

Absence of breath sounds; due to partial or total collapse of the lung

A child has a prescription to receive chest physiotherapy (CPT). Which of the following should the nurse do? 1. perform CPT 15 min prior to meals 2. perform CPT immediately after the child eats 3. administer albuterol prior to CPT 4. perform CPT prior to administering albuterol

Administer albuterol prior to CPT; bronchodilators relax and dilate the airway to promote air exchange. Facilitates removal of the secretions as the chest wall is being percussed.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? 1. initiating oxygen therapy 2. providing immediate rest for the client 3. positioning the client in high fowlers 4. administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic; decrease the inflammatory response that triggers narrowing of the airways. Provides prompt relief of airflow obstruction

The nurse is caring for a client with a chest tube. The nurse understands that continuous air bubbling in the water-seal chamber may indicate which situation? 1. air is passing out of the pleural space 2. air is being removed from within the lung tissue 3. air is leaking into the drainage system 4. such bubbling is expected

Air is leaking into the drainage system; make sure all connections are tight and taped.

A nurse is caring for a client admitted with major burns of the head, neck, and chest. In planning the client's care, the nurse is aware that the client is at the greatest risk for 1. hypothermia 2. hyponatremia 3. fluid imbalance 4. airway obstruction

Airway obstruction; may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation

A nurse collecting data from a client who is 2 days postop auscultates bilateral breath sounds but absent breath sounds in the bases. The nurses should suspect which of the following postop complications. 1. Atelectasis 2. Rales 3. Rhonchi 4. Pneumothorax

Atelectasis; incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration? 1. continue to monitor the client 2. immediately notify the provider 3. reposition the client toward the left side 4. clamp the chest tube near the water seal

Continue to monitor the client; the fluid in the water seal chamber rises 2-4 inches during inhalation and falls during exhalation

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1. resting in a supine position 2. elevating arms while performing ADLs 3. breathing in through her nose and out through pursed lips 4. increasing oxygen delivery to 5 L/min during times of distress

Breathing in through her nose and out through pursed lips; slows expirations, prevents collapse of alveoli, and helps client control the rate and depth of respirations

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority? 1. palpating peripheral pulses 2. auscultating heart sounds 3. confirming the gag reflex 4. measuring blood pressure

Confirming the gag reflex; greatest risk is aspiration resulting from depressed gag reflex.

A nurse is preparing to measure a client's level of oxygen saturation and notes edema of both of the client's hands and thickened toe nails. The nurse should apply pulse ox probe to which of the following locations? 1. finger 2. earlobe 3. toe 4. skin fold

Earlobe; earlobe is rarely edematous, is least affected by decreased blood flow, and has better accuracy when oxygen saturation decreases.

A nurse is caring for a client diagnosed with COPD who has tenacious bronchial secretions. Which of the following actions should the nurse perform? 1. encouraging the client to drink 8 glasses of water a day 2. administering oxygen via nasal cannula at 3 L/min 3. helping the client select a low-salt diet 4. maintaining the client in a semi-Fowlers position as much as possible

Encouraging the client to drink 8 glasses of water a day; will help to liquefy the tenacious (thick) secretions.

A nurse is caring for a client diagnosed with CHF who experiences respiratory arrest. Which of the following is the first action the nurse should take? 1. establish IV access 2. feel for a carotid pulse 3. establish an open airway 4. auscultate for breath sounds

Establish an open airway

A nurse is caring for a client who has a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1. increase fluid intake 2. perform chest physiotherapy prior to suctioning 3. pre-lubricate the suction catheter tip with sterile saline when suctioning the airway 4. hyperventilate the client with 100% oxygen before suctioning the airway

Increase his fluid intake; also providing adequate humidification.

A nurse is reinforcing nutritional teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate? 1. drink carbonated beverages 2. decrease fiber intake 3. use bronchodilators after meals 4. increase protein intake

Increase protein intake; pulmonary diseases increases metabolic demands and can cause anorexia or fatigue

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicates a complication that requires notifying the provider immediately? 1. serosanguineous drainage from puncture site 2. discomfort at puncture site 3. increased heart rate 4. decreased temperature

Increased heart rate; clients can develop pulmonary edema or cardiovascular distress after mediastinal content shift suddenly.

A nurse is caring for a client who has a chest tube in place due to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? 1. O2 sat 95% 2. no fluctuations in the water seal chamber 3. no reports of pleuritic chest pain 4. occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber; fluctuation stop when the lung has re-expanded or when the tubing is obstructed

A nurse is caring for a client who reports pleuritic pain on the right side. The nurse notices that the client has dyspnea, decreased movement of the chest wall, and absent breath sounds on the right side. The nurse should suspect that the client has which of the following? 1. pleural effusion 2. pulmonary embolism 3. pulmonary infection 4. empyema

Pleural effusion; manifestations of pleural effusion are dyspnea, decreased movement of the chest on the affected side. There may be pleuritic pain and absent or decreased breath sounds over affected area.

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following should the nurse include as effective for preventing this order? 1. Maintenance of ideal weight 2. annual influenza immunization 3. smoking cessation 4. regular moderate exercise

Smoking cessation

A nurse is caring for a client who is 1 day postop following a left lower lung lobectomy. When checking the client's closed chest drainage system, the nurse notes that there is no bubbling in the suction control chamber. The nurse should 1. notify the provider 2. verify that the suction regulator is on 3. continue to monitor the client as this is an expected finding 4. milk the chest tube to dislodge any clots in the tubing that may be occluding it

Verify that the suction regulator is on

A nurse is preparing information for a client who has tuberculosis. Which of the following should the nurse include? 1. take the medication each morning 2. sputum cultures will be needed every 6 weeks 3. alcohol consumption is permitted while on the drug therapy 4. wear a mask in crowds until the drugs suppress the infection

Wear a mask in crowds until the drugs suppress the infection