Respiratory

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1.Reduce fluid intake to less than 1500 mL/day. 2.Teach diaphragmatic and pursed-lip breathing. 3.Encourage alternating activity with rest periods. 4.Teach the client techniques of chest physiotherapy. 5.Keep the client in a supine position as much as possible.

2.Teach diaphragmatic and pursed-lip breathing. 3.Encourage alternating activity with rest periods. 4.Teach the client techniques of chest physiotherapy.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

1.Cough 2.Dyspnea 5.Chills and night sweats

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1.Dyspnea 2.Bradypnea 3.Bradycardia 4.Decreased respirations

1.Dyspnea

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1.Focus only on the physical examination. 2.Obtain all information from family members. 3.Use the health care provider's medical history. 4.Plan short sessions with the client to obtain data.

4.Plan short sessions with the client to obtain data.

ABG pH 7.34 CO2 50 HCO3 32 How would you interpret these findings?

Respiratory acidosis

A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee? a. Appropriate; oral intake after the procedure may result in aspiration b. Appropriate; it is important to limit painful swallowing c. Inappropriate; the client is too groggy after general anesthesia to comprehend information d. Inappropriate; fluid replacement should begin immediately after the procedure

a. Appropriate; oral intake after the procedure may result in aspiration

Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. a. Elevated levels of partial arterial oxygen b. Elevated levels of eosinophils c. Elevated levels of neutrophils d. Elevated levels of red blood cells e. Elevated levels of peripheral capillary oxygen saturation

b. Elevated levels of eosinophils c. Elevated levels of neutrophils d. Elevated levels of red blood cells Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear? a. Snorting sounds during the inspiratory phase b. Moist rumbling sounds that clear after coughing c. Musical sounds more pronounced during expiration d. Crackling inspiratory sounds unchanged with coughing

b. Moist rumbling sounds that clear after coughing

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? a. Question the client about the confusion. b. Change the method of oxygen delivery. c. Percuss and vibrate the client's chest wall. d. Discontinue or decrease the oxygen flow rate.

d. Discontinue or decrease the oxygen flow rate.

A client is admitted to the emergency department with multiple injuries, including fractured ribs. Which assessment is priority? a. Pneumonitis b. Hematemesis c. Pulmonary edema d. Respiratory acidosis

d. Respiratory acidosis Fractured ribs cause extreme pain, especially on inhalation; this induces shallow breathing, which results in carbon dioxide retention, leading to respiratory acidosis

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1."It hurts more when I breathe in." 2."I have never had this pain before." 3."It hurts on the left side of my chest." 4."The pain is about a 6 on a scale of 1 to 10."

1."It hurts more when I breathe in." Note the strategic words, most likely. Note the words respiratory origin. This phrasing indicates that the correct answer is an item that will discriminate respiratory from nonrespiratory conditions. Note the relationship between the words respiratory origin and the phrase when I breathe in in the correct option.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing

1.Positive

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1.Cyanosis 2.Hyperinflated chest 3.Rapid, shallow respirations 4.Coarse crackles auscultated bilaterally

3.Rapid, shallow respirations

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1.A low arterial PCo2 level 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. 1.Purified air 2.Cigarette smoking 3.Genetic risk factor 4.Environmental factors 5.Eating plenty of fruits and vegetables 6.Alpha-1 antitrypsin (AAT) deficiency

2.Cigarette smoking 3.Genetic risk factor 4.Environmental factors 6.Alpha-1 antitrypsin (AAT) deficiency

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? 1.Increase to 3 L/min and titrate until the SpO2 is 95%. 2.Increase to 3 L/min and titrate until the SpO2 is 88%. 3.Place the client on a nonrebreather mask on 100% FiO2. 4.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

2.Increase to 3 L/min and titrate until the SpO2 is 88%.

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? 1.Positive 2.Negative 3.Uncertain 4.Borderline

2.Negative

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1.A 25-year-old woman with diabetic ketoacidosis 2.A 65-year-old man out of bed 1 day after prostate resection 3.A 73-year-old woman who has just had pinning of a hip fracture 4.A 38-year-old man with pulmonary contusion sustained in an automobile crash

3.A 73-year-old woman who has just had pinning of a hip fracture

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? 1.An uninsured man who is homeless 2.A newly immigrated woman from Korea 3.A man who is an inspector for the U.S. Postal Service 4.An older woman admitted from a long-term care facility

3.A man who is an inspector for the U.S. Postal Service

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? 1.Do not exceed 1 L/min. 2.Do not exceed 2 L/min. 3.Adjust the oxygen depending on SpO2. 4.Adjust the oxygen depending on respiratory rate.

3.Adjust the oxygen depending on SpO2.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? 1.Instruct the client to limit fluid intake. 2.Place the client in low Fowler's position. 3.Administer the prescribed bronchodilator. 4.Place a continuous pulse oximeter on the client.

3.Administer the prescribed bronchodilator.

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1.Promote oxygen intake. 2.Strengthen the diaphragm. 3.Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.

4. Promote carbon dioxide elimination.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? 1.Low cardiac output secondary to cor pulmonale 2.Gas exchange alteration related to ventilation-perfusion mismatch 3.Altered breathing pattern secondary to increased work of breathing 4.Inability to clear the airway related to inability to expectorate sputum

4.Inability to clear the airway related to inability to expectorate sputum

The nurse assesses a client with emphysema. The nurse expects to find which sign of chronic obstructive pulmonary disease (COPD)? a. Increased breath sounds b. Atrophic accessory muscles c. Shortened expiratory phase of the respiratory cycle d. Chest with an increased anteroposterior (AP) diameter

d. Chest with an increased anteroposterior (AP) diameter

ABG pH 7.25 CO2 36 HCO3 20

metabolic acidosis

You have a patient that presents with the following labs: pH 7.30, CO2 of 20, HCO3 of 26. What is their ABG?

metabolic acidosis

pH= 7.33 PaCO2= 25 HCO3=12

metabolic acidosis

ABG pH 7.20 CO2 85 HCO3 25

respiratory acidosis

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Lying on the back in a low Fowler's position 4.Sitting up with the elbows resting on the knees

3.Lying on the back in a low Fowler's position

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken

3.Chest pain that occurs suddenly

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

3.Encouraging active range-of-motion exercises

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1.Sitting up in bed 2.Side-lying in bed 3.Sitting in a recliner chair 4.Sitting up and leaning on an overbed table

4.Sitting up and leaning on an overbed table

The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? a. Arterial oxygen saturation b. Partial pressure of oxygen in arterial blood c. Partial pressure of arterial carbon dioxide d. Partial pressure of oxygen in venous blood

a. Arterial oxygen saturation

After a spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increase. What do these client responses indicate to the nurse? a. Hypercapnia b. Hypokalemia c. Increased PO2 d. Respiratory alkalosis

a. Hypercapnia

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? a. "I will use only grounded electrical equipment." b. "I have a new woolen blanket to keep me warm." c. "I have told my family they cannot smoke in the house." d. "I will keep a pitcher of water near me so I drink enough."

b. "I have a new woolen blanket to keep me warm."

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? a. "I will try to avoid smoking." b. "I will maintain complete bed rest." c. "I'll control the temperature in my home." d. "I'll need to clean my mouth several times a day."

b. "I will maintain complete bed rest."

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first? a. Obtain vital signs. b. Administer oxygen. c. Call the healthcare provider. d. Place the client in the high-Fowler position.

b. Administer oxygen.

ABG pH 7.48 CO2 28 HCO3 22

respiratory alkalosis

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? a. Prepare for a thoracentesis. b. Apply a wound dressing. c. Obtain baseline vital signs. d. Suction fluid from the wound.

b. Apply a wound dressing.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment

1.Activities should be resumed gradually. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? 1.Increased oxygen saturation with ambulation 2.A widened diaphragm documented by chest x-ray 3.Hyperinflation of lungs documented by chest x-ray 4.A shortened expiratory phase of the respiratory cycle

3.Hyperinflation of lungs documented by chest x-ray

What are some signs that your patient diagnosed with right sided heart failure might exhibit? Select all that apply. A. SOB at rest and exertion B. Pitting edema of +3 on the ankles C. Crackles in the left lower lobe D. LOC changes E. Weight gain of 3 pounds in 2 days

A. SOB at rest and exertion B. Pitting edema of +3 on the ankles E. Weight gain of 3 pounds in 2 days

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. What should the nurse suggest to the client? a. Use a humidifier in the bedroom. b. Sleep with two or more pillows. c. Cough regularly even if the cough does not produce sputum. d. Cough and deep breathe each night before going to sleep.

a. Use a humidifier in the bedroom.

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. a. Anxiety b. Oxygenation c. Drowsiness d. Mental confusion e. Increased respirations

b. Oxygenation c. Drowsiness d. Mental confusion Clients with chronic obstructive pulmonary disease (COPD) respond to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will decrease the stimulus to breathe, leading to decreased respirations, lethargy, and drowsiness. Oxygenation should be monitored to keep levels within a range to provide adequate oxygen without decreasing the client's drive to breathe. Clients with COPD experience the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Increased levels of carbon dioxide depress the central nervous system, causing mental confusion and a lowered level of consciousness. Rising carbon dioxide levels cause lethargy rather than anxiety.

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises? a. Spend more time inhaling than exhaling to blow off carbon dioxide b. Perform diaphragmatic exercises to improve contraction of the diaphragm c. Perform sit-ups to strengthen abdominal muscles to improve breathing d. Use abdominal exercises to limit the use of accessory muscles of respiration

b. Perform diaphragmatic exercises to improve contraction of the diaphragm

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? a. Productive coughing b. Return of breath sounds c. Increased pleural drainage in the chamber d. Constant bubbling in the water-seal chamber

b. Return of breath sounds

A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for? a. Prostatitis b. Tuberculosis c. Osteoarthritis d. Diverticulosis

b. Tuberculosis

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? a. Postural drainage b. Turning and positioning c. Administration of an expectorant d. Percussion and vibration techniques

b. Turning and positioning

The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? a. Careful monitoring for crepitus b. Bed rest with range-of-motion exercises c. Coughing and deep breathing every hour d. Covering the chest tube site with a sterile dressing

c. Coughing and deep breathing every hour

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? a. Excessive fluid intake b. Inadequate chest expansion c. Extension of cancerous lesions d. Irritation from the bronchoscopy

c. Extension of cancerous lesions

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply. a. Vomiting b. Weight gain c. Hemoptysis d. Night sweats e. Bilateral crackles

c. Hemoptysis d. Night sweats

A client who is admitted with emphysema shows progressive respiratory failure and has a Paco2 of 60. To address the problems, the nurse expects to receive a prescription for: a. Mucolytics b. Bronchodilators c. Mechanical ventilation d. Intermittent positive-pressure breathing (IPPB)

c. Mechanical ventilation

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? a. Put on a gown when entering the room b. Place the client with another client who has TB c. Wear a particulate respirator when caring for the client d. Don a surgical mask with a face shield when entering the room

c. Wear a particulate respirator when caring for the client

Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. What is the priority nursing intervention? a. Facilitate verbal communication b. Prepare the client for emergency surgery c. Maintain sterility of the ventilation system d. Assess the client's response to the mechanical ventilation

d. Assess the client's response to the mechanical ventilation

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? a. Weak, rapid pulse b. Decreased blood pressure c. Radiating anterior chest pain d. Crackles at bases of the lungs

d. Crackles at bases of the lungs

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings? a. Increased leukocyte development in response to infection b. Decreased extracellular fluid volume secondary to infection c. Decreased red blood cell proliferation because of hypercapnia d. Increased erythrocyte production as a result of chronic hypoxia

d. Increased erythrocyte production as a result of chronic hypoxia

Which diagnostic test may be used to distinguish vascular from nonvascular structures? a. Chest X-ray b. Pulmonary angiogram c. Computed tomography d. Magnetic resonance imaging

d. Magnetic resonance imaging

A client with a sucking chest wound has a large, tight dressing over the site. Which purpose of the dressing does the nurse consider when planning care for this client? a. Protects the lung b. Seals off major vessels c. Prevents additional contamination of the wound d. Maintains the appropriate pressure within the chest cavity

d. Maintains the appropriate pressure within the chest cavity

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? a. Retrospective 24-hour calorie count b. Elimination pattern during the last 30 days c. Complete gynecological and sexual history d. Presence of a cough and pulmonary secretions

d. Presence of a cough and pulmonary secretions