Respiratory

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? 1 Respiratory alkalosis 2 Poor oxygen perfusion 3 Normal acid-base balance 4 Compensated metabolic acidosis

Correct Ans: 3 All data are within expected limits; PO2 is 80 to 100 mm Hg, PCO2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within the expected limits of 80 to 100 mm Hg. With metabolic acidosis, the pH is less than 7.35.

The nurse reviews teaching with a client who has laryngeal cancer and is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client makes which statement about what he will be able to do after recovering from surgery? 1 After surgery, I will still be able to blow my nose. 2 After surgery, I will still be able to sip through a straw. 3 After surgery, I will still be able to chew and swallow food. 4 After surgery, I will still be able to smell and differentiate odors.

Correct Ans: 3 There is still a pathway from the mouth to the stomach; eating patterns are not lost when a laryngectomy is performed. Air passes through a tracheal stoma that bypasses the nose and olfactory organs. There is no passage of air from the lungs to the nose; air is expelled through a tracheal stoma.

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. 1 Vomiting 2 Weight gain 3 Hemoptysis 4 Night sweats 5 Bilateral crackles

I put 1, 3, 4, 5 Ans: 3 & 4 Erosion of lung tissue causes blood in the sputum, a classic sign of tuberculosis. Increased body temperature causes profuse diaphoresis, a classic sign of tuberculosis. Vomiting is associated with a gastrointestinal (GI) obstruction or cancer. Weight loss, not weight gain, is a sign of tuberculosis. Bilateral crackles are associated with excess fluid volume.

The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment? 1 A mediastinal shift may have occurred. 2 Subcutaneous emphysema may be present. 3 Tracheal edema may lead to an obstructed airway. 4 The cuff of the endotracheal tube may be underinflated.

I put 3 Ans: 1 After a pneumonectomy, the mediastinum may shift toward the remaining lung, or the remaining lung may shift toward the empty space, depending on the pressure within the empty space. Either of these shifts will cause the trachea to move from its usual midline position; this is known as a mediastinal shift. Subcutaneous emphysema is found by palpation over the lungs and chest areas. Tracheal edema cannot be assessed through palpation. The cuff of the endotracheal tube cannot be assessed through palpation of the trachea.

The nurse is providing care during the immediate postoperative period for a client who had a radical neck dissection. What is the best method to assess for stridor? 1 Listen with a stethoscope over the trachea 2 Determine the client's ability to do neck exercises 3 Listen with a stethoscope over the base of the lungs 4 Determine the client's ability to cough and deep breathe

I put 3 Ans: 1 Stridor is a high-pitched, harsh sound caused by an obstruction of the trachea or larynx. Neck exercises are important for total rehabilitation; neck exercises do not help identify stridor. Auscultating the base of the lungs will determine the presence of vesicular breath sounds or crackles. Although coughing and deep breathing are important, they do not help identify stridor.

A nurse is suctioning a client's tracheostomy. Place the nursing actions in order of priority when performing this procedure. 1. Don sterile gloves. 2. Auscultate the lungs and check the heart rate. 3. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 4. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. 5. Hyperoxygenate using 100% oxygen.

The status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning [1] [2], the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.

The nurse understands that clients with emphysema experience which pathophysiologic change in the alveolar sacs? 1 They collapse. 2 They retain CO2. 3 They become fluid filled. 4 They become overdistended.

I put 2 Ans: 4 Clients with emphysema experience changes in the alveolar sacs when they lose elasticity. Trapped air causes the sacs to become distended and can cause them to rupture. This in turn impairs gas exchange. The alveolar sacs do not collapse; however, they can rupture. The sacs do not retain CO2; nor do they become fluid filled.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? 1 PO2 value is 80 mm Hg. 2 PCO2 value is 60 mm Hg. 3 HCO3 value is 50 mEq/L (50 mmol/L). 4 Serum potassium value is 4 mEq/L (4 mmol/L).

I put 3 Ans: 2 The HCO3 value is elevated. The urinary system compensates by retaining H+ ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis [1] [2] the PCO2 level may be increased, it is the increased HCO3 level that indicates compensation. A K+ level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activity of the client might have led to this condition? 1 Using nasal saline sprays 2 Using drugs such as aspirin 3 Blowing the nose vigorously 4 Applying excess petroleum jelly to the nares

I put 3 Ans: 4 The sparing application of petroleum jelly to the nares helps to lubricate the area and provide comfort to the client. However, excess use may cause inhalation of the jelly into the lungs and may increase the risk of pneumonia. Nasal saline sprays are used to moisten the nares and prevent re-bleeding. Medications such as aspirin should be avoided after the placement of an epistaxis catheter to prevent bleeding. Vigorous nose blowing does not cause pneumonia.

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do first? 1 Inspect the catheter 2 Notify the healthcare provider 3 Clamp the remaining device 4 Assess respiratory status

I put 4 Ans: 1 The nurse should first assess the catheter to see if anything may have broken off. Anything that damages the catheter during insertion, dressing change, or excessive force may cause a catheter embolism, which could be a life-threatening situation. If the catheter is broken, the nurse should do a quick respiratory assessment and vital signs.

The nurse provides a teaching session related to the severe acute respiratory syndrome (SARS) virus to a group of nursing students. It is appropriate for the nurse to include which virus associated with SARS? 1 Malaria 2 Aspergillosis 3 The common cold 4 Legionnaires disease

I put 4 Ans: 3 One of the causes of both SARS and the common cold is the coronavirus. Malaria is caused by a species of the protozoan Plasmodium. Aspergillosis, a fungus that affects the lungs, is from Aspergillus fumigatus. Legionnaires disease is caused by a bacterium of the genus Legionella pneumophila.

The nurse is performing a physical assessment of a newly admitted client. Identify the area of the chest on the illustration that produces resonance when percussed. (unable to attach image)

Percussion over air-filled lung tissue causes a resonant sound. Percussion over dense tissue, such as bone or muscle, causes a flat sound. Percussion over a solid organ, such as the liver or heart, causes a dull sound. Percussion over the air-filled stomach causes tympany.

A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph? 1 Cavities caused by caseation 2 Sensitized T cells 3 Presence of acid-fast bacilli 4 Microscopic primary infection

Correct Ans: 1 Cavities are evident on radiograph. Necrotic lung tissue may liquefy, leaving a cavity (cavitation), or granulose tissue can surround the lesion, become fibrous, and form a collagenous scar around the tubercle (Ghon tubercle). Sensitized T cells are determined by a positive reaction to a tuberculin skin test, not on radiograph; a skin test only determines the presence of antibodies; it does not confirm active disease. Presence of acid-fast bacilli may be determined by a sputum culture, not by radiograph. Microscopic primary infection may be so small it does not appear on a radiograph.

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? 1 Prolonged exhalation to decrease air trapping 2 Shortened inhalation to reduce bronchial swelling 3 Increased respiratory rate to improve arterial oxygenation 4 Decreased use of diaphragm to increase amount of inspired air

Correct Ans: 1 Pursed-lip breathing works to decrease dyspnea and the respiratory rate through prolonging exhalation and prevention of alveolar collapse. PLB does not increase the length of inhalation and does not increase the respiratory rate. Use of the diaphragm occurs with diaphragmatic, or abdominal, breathing.

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? 1 Increased restlessness 2 No secretions when client is suctioned 3 PaO2 of 93 4 Skin warm and dry

Correct Ans: 1 Signs of poor oxygenation in the client on a ventilator may include, but are not limited to, the following: cyanosis; PaO2 less than 90; increased restlessness or agitation; skin pale, cool, and clammy; and thick, tenacious secretions present when suctioned.

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room? 1 Suction supplies 2 Writing materials 3 Tracheostomy set 4 Incentive spirometer

Correct Ans: 1 Suction equipment is the priority. Respiratory complications can occur after a laryngectomy is performed because of the production of excessive secretions, edema of the glottis, or injury to the recurrent laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively to raise secretions. Although writing supplies along with a picture board are helpful for promoting communication, they are not the priority. A tracheostomy set is unnecessary. When a laryngectomy is performed a permanent stoma in the trachea is surgically created, and a laryngectomy tube is in place. An additional sterile laryngectomy tube and obturator should be kept at the bedside. A client with a tracheal stoma cannot use an incentive spirometer.

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? 1 Administer oxygen as prescribed. 2 Notify the healthcare provider. 3 Assist with insertion of chest tube. 4 Continue to assess client's respiratory status.

Correct Ans: 1 The client most likely is experiencing a pneumothorax, which is a collection of air in the pleural space. This can be caused during the insertion of a central venous catheter. During insertion, the pleural covering of the lung can be punctured by the introducer on insertion of a direct subclavian approach. Signs and symptoms of a pneumothorax include chest pain, dyspnea, apprehension, cyanosis, decreased breath sounds on the affected side, and abnormal chest x-ray findings. The nurse should first think about the "ABC's" (airway, breathing, circulation) and therefore should administer oxygen as prescribed, then notify the healthcare provider, continue to assess the client's respiratory status, and then assist with chest tube insertion if indicated.

A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan? 1 Importance of cleanliness around the site of the stoma 2 Necessity of covering the tube opening while swimming 3 Establishment of a regular schedule for suctioning the tube 4 Usage of sterile technique when caring for the tracheostomy tube

Correct Ans: 1 The procedure should be explained so the client understands that the tracheostomy can serve as an entrance for bacteria and that cleanliness is imperative. Clients with a laryngectomy may no longer swim because water will flood the lungs. Suctioning must be performed only as needed; a pattern is not necessary. Sterile technique is not required; medical aseptic technique is adequate and realistic.

The nurse is teaching a client with asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of how to use a peak flow meter? Select all that apply. 1 "Readings in the green zone mean that my asthma is under control." 2 "If I get a reading in the yellow zone, I need to stop what I'm doing and rest, then recheck in an hour." 3 "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." 4 "I should check the peak flow readings at least twice a day." 5 "I don't need to check my peak flow readings if I take a reliever drug."

Correct Ans: 1, 2, 3, 4 Peak flow meters are used to measure how well the client's asthma is controlled. Readings in the green zone mean the asthma is under control; however, readings in the red zone indicate a serious respiratory problem that needs to be addressed immediately. The client will need to take a reliever drug and seek emergency help immediately. Peak flow readings need to be measured twice a day. If a reading in the yellow zone occurs, the client should use the reliever drug and then measure the peak expiratory flow (PEF) again in a few minutes to determine whether the drug is working. Improvement in PEF should be seen. Clients need to check the PEF any time a reliever drug is used to determine the drug's effectiveness.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. Which information in the client's history supports the healthcare provider's diagnosis of pulmonary tuberculosis? Select all that apply. 1 Fever 2 Dry cough 3 Night sweats 4 Frothy sputum 5 Engorged neck veins 6 Blood-tinged sputum

Correct Ans: 1, 3, 6 Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, not dry, because the inflammatory process causes purulent mucus. Frothy sputum is present with pulmonary edema, not tuberculosis. Engorged neck veins are symptomatic of heart failure or fluid overload.

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply. 1 Dry cough 2 Chest pain 3 Hemoptysis 4 Shortness of breath 5 Fever greater than 100.4° F (38° C)

Correct Ans: 1. 4. 5 Between two and seven days after the onset of SARS, which is caused by a coronavirus, clients exhibit a dry cough. SARS is an acute viral respiratory infection that results in respiratory signs and symptoms, including difficulty breathing and shortness of breath. SARS, a viral infection, generally begins with a fever greater than 100.4° F (38° C), headache, and muscle weakness. Although clients may exhibit sinus tachycardia, chest pains are not a typical symptom associated with SARS. The cough associated with SARS is nonproductive, and hemoptysis does not occur.

A nurse teaches a client with a nose fracture about routine care after rhinoplasty surgery. Which statement of the client indicates the need for further teaching? 1 "I should not sniff upwards or blow my nose." 2 "I should take aspirin if I experience bleeding." 3 "I should move slowly and remain in the semi-Fowler's position whenever possible." 4 "I should not cough forcefully or strain during bowel movements."

Correct Ans: 2 After a rhinoplasty, aspirin and other NSAIDs are avoided in order to prevent bleeding. Sniffing upwards or blowing the nose may cause nasal strain and lead to complications. Moving slowly and remaining in the semi-Fowler's position may not cause stress on the nose. Forceful coughing and straining during bowel movements may lead to nasal bleeding.

A nurse is teaching a client about self-management techniques for smoking cessation. Which statement made by the client indicates the need for further teaching? 1 "I should list the reasons why I should stop smoking." 2 "I should visit all the places where I started smoking." 3 "I should remove all ashtrays and lighters." 4 "I should try replacing tobacco with sugarless mints and gum."

Correct Ans: 2 Clients may be tempted to smoke if they visit the places where they started smoking. Listing the reasons to stop smoking may help the client to prevent smoking. Removing ashtrays and lighters from the environment may help the client to prevent smoking. When the client is tempted to smoke, sugarless mints and gums may act as good substitutes for tobacco smoking.

A client returned to the unit following abdominal surgery. Which assessment finding should be reported to the surgeon immediately? 1 Respiratory rate of 10 to 12 during deep sleep. 2 Oxygen saturation drops to 90% from admission 99% saturation. 3 Complaints of pain during deep breathing and coughing exercises. 4 Breath sounds diminished in lung bases prior to deep breathing exercises.

Correct Ans: 2 If the oxygen saturation drops below 95% (or below the client's presurgery baseline), the nurse should notify the surgeon or anesthesia provider. If it drops by 10 percentage points and it is an accurate measure, the rapid response team should be called. The other findings, lower respiratory rate during sleep, pain on cough and deep breathing exercises and diminished breath sounds from shallow breathing prior to exercises are normal findings.

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion? 1 The client leans forward while coughing. 2 The client smokes four cigarettes per day. 3 The client avoids showering and swimming. 4 The client uses a non-oil-based ointment to lubricate the stoma.

Correct Ans: 2 Smoking can increase the risk for developing other cancers such as lung cancer and can decrease the rate of healing from laryngeal surgeries. Leaning forward while coughing promotes healing. Avoiding showering and swimming helps to prevent water from entering the airways through the stoma. Using a non-oil-based ointment to lubricate the stoma may aid in quick healing.

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? 1 Prepare for a thoracentesis. 2 Apply a wound dressing. 3 Obtain baseline vital signs. 4 Suction fluid from the wound.

Correct Ans: 2 The wound must be covered to prevent atmospheric air from entering the pleural cavity until closed chest drainage can be instituted. While some sources specify an airtight dressing, others suggest that a side or corner of the dressing be left unsecured to prevent tension pneumothorax. A thoracentesis is used to drain fluid from lungs. Obtaining baseline vital signs will be done eventually; they are not the priority. Suctioning fluid from the wound is traumatic to lung tissue and is contraindicated.

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Obtain blood specimens for C & S. 2. Promote bed rest with raised head of bed. 3. Administer prescribed antibiotic. 4. Provide oxygen via nasal cannula.

Correct Ans: 2, 4, 1, 3 The client's respiratory status is the priority. Promoting bed rest with raised head of bed reduces oxygen demand and administering oxygen via nasal cannula increases the supply of oxygen to the alveolar capillaries. Obtaining specimens for culture and sensitivity must be performed before administering antibiotics, which prevents false microbiologic interpretation caused by the effect of the antibiotic.

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. 1 Anxiety 2 Oxygenation 3 Drowsiness 4 Mental confusion 5 Increased respirations

Correct Ans: 2. 3. 4 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 nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during swallowing. Which statement of the client indicates the need for further teaching? 1 "I should eat smaller and more frequent meals." 2 "I should avoid eating meals when I am fatigued." 3 "I should drink more water and other thin liquids." 4 "I should keep emergency suctioning equipment close at hand."

Correct Ans: 3 A client with a tracheotomy is at risk of aspirating food, gastric contents, or oral secretions into the lungs. Water and other thin liquid consumption should be avoided because these substances have higher chances of entering the lungs. Thicker liquids are advised because they are easier to swallow. Consuming smaller and more frequent meals may help to ease swallowing and prevent aspiration. Consuming meals in a fatigued condition may lead to aspiration due to inadequate efforts of swallowing. Placing emergency suction equipment close at hand may help to eliminate sudden aspiration.

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? 1 Assess frequently for nasal drying. 2 Keep the mask tight against the face. 3 Monitor oxygen saturation levels when eating. 4 Set the oxygen flow at the highest setting possible.

Correct Ans: 3 Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating. Nasal drying usually is not a problem with the use of a Venturi mask. Nasal drying occurs more frequently when a nasal cannula is used. Too tight a fit for the mask is uncomfortable and may cause damage to the skin. The mask should fit snugly but not be too tight. The oxygen should be set at the level prescribed by the healthcare provider.

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? 1 Class I 2 Class II 3 Class III 4 Class IV

Correct Ans: 3 Dyspnea during activities such as showering and dressing and the ability to walk for more than a city block, but only at their own pace without being able to keep up with others, indicates class III dyspnea. The client belonging to class I shows dyspnea on more-than-normal or strenuous exertion. The client belonging to class II shows dyspnea on climbing stairs or on walking on an incline but not during level walking. The client belonging to class IV dyspnea requires assistance in some essential activities of daily living such as dressing and bathing due to dyspnea. This client is not usually dyspneic at rest.

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result? 1 Osmosis 2 Filtration 3 Active transport 4 Molecular diffusion

Correct Ans: 4 Decreased surface area affects diffusion. The respiratory membrane, consisting of alveolar and capillary walls, is extremely thin. Thinness facilitates exchange of respiratory gases by diffusion without the need for additional energy; molecules move from an area of higher concentration to an area with lower concentration. Osmosis is the passage of water through a semipermeable membrane from an area of lower solute concentration to an area of greater solute concentration. Filtration is the process in which fluid and solutes move across a membrane; it prevents the passage of particles of a particular size. Active transport is used when energy is required to move matter against a concentration gradient.

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action by the nurse is the first line of defense against an emerging influenza pandemic? 1 Complying with quarantine measures 2 Instituting strict international travel restrictions 3 Seeking aid from the international public health community 4 Reporting surveillance findings to appropriate public health officials

Correct Ans: 4 Honesty and openness are essential to understanding the extent of the problem so that an appropriate local and global response can be mobilized to limit emerging pandemics. While complying with quarantine measures helps, it can only be done in response to detecting and reporting the presence of an emerging health problem. Nurses do not institute strict international travel restrictions. While the nurse can seek aid from the international public health community, the nurse's responsibility of monitoring and reporting takes precedence.

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff? 1 Deflate the cuff before starting each tube feeding 2 Inflate the cuff for one hour before and after each feeding 3 Deflate the cuff after the tube feeding has been completed 4 Inflate the cuff before the feeding and for 30 minutes after each feeding

Correct Ans: 4 Inflating the tracheostomy cuff before and for 30 minutes after each feeding occludes the tracheal lumen around the tracheostomy tube, preventing aspiration if regurgitation occurs. Deflating the tracheostomy cuff before starting a tube feeding will permit aspiration if regurgitation occurs. Although the cuff must be inflated during the tube feeding as well as after to prevent aspiration, it is done just before feeding, not one hour before. Deflating the tracheostomy cuff after the tube feeding has been completed will permit aspiration if regurgitation occurs.

A client is admitted with possible tuberculosis. To make a definitive diagnosis, the nurse expects which diagnostic test to be prescribed? 1 Chest x-ray film 2 Tuberculin skin test 3 Pulmonary function test 4 Sputum test for acid-fast bacilli

Correct Ans: 4 When the tubercle bacilli are stained with an acid, they turn red and are not decolorized by an acid-alcohol wash; they are acid fast. The rods are visible upon microscopic examination. Chest x-ray film reflects pulmonary status but does not identify the organism if a lesion is found. Tuberculin skin test indicates the presence of antibodies but is not diagnostic of the disease; it just means the client has been exposed. Pulmonary function test reflects pulmonary status but does not identify the organism if a lesion is found.

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of? 1 The drainage system will be disconnected from the chest tube. 2 A chest x-ray will be performed to determine lung re-expansion. 3 An arterial blood gas will be obtained to determine oxygenation status. 4 The client will be sedated 30 minutes before the procedure.

I put 1 Ans: 2 A chest x-ray should be performed to ensure and to document that the lung is reexpanded and has remained expanded. The drainage system should not be disconnected from the actual chest tube while still in the client because this may cause a pneumothorax to recur. An arterial blood gas may be performed before removal, but is not necessary. An oxygen saturation reading with a pulse oximeter is usually sufficient to determine oxygenation level. The client may be given pain medication before the procedure, but not sedation, as this may decrease the oxygen status.

A client with obstructive airway disease reports to the nurse about experiencing spasms of coughing. What suggestion should the nurse provide to help the client successfully manage this problem? 1 Limit the intake of highly seasoned foods. 2 Postpone the planned vacation to go skiing. 3 Use aerosolized cleaning products when dusting. 4 Perform mild physical exercise when breathing difficulties occur.

I put 1 Ans: 2 Extreme temperature changes should be avoided, especially environmental heat or cold, because they promote bronchospasms. Food restrictions usually are not necessary. Aerosol sprays increase exposure to irritating and noxious substances that irritate bronchial mucosa and initiate bronchospasms. Exercise in the presence of breathing difficulties will exacerbate dyspnea.

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? 1 Checking for capillary refill 2 Encouraging increased fluid intake 3 Suctioning secretions from the airway 4 Administering a high concentration of oxygen

I put 1 Ans: 2 Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve 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.

A nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which statement made by the client indicates the need for further teaching? 1 "I will wait for at least 1 minute between puffs." 2 "I will shake the whole unit vigorously one or two times." 3 "I will hold my breath for at least 10 seconds after removing the mouthpiece." 4 "I will insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer."

I put 1 Ans: 2 The metered-dose inhaler should be shaken vigorously for a minimum of three or four times for proper mixing of the content inside the inhaler. A minimum of a 1-minute gap should be given in between the puffs to ensure proper movement of the medications into the lungs. After removing the mouthpiece, the client should hold his/her breath for at least 10 seconds so that the drug does not escape with exhalation. Inserting the mouthpiece of the inhaler into the nonmouthpiece end of the spacer is the correct way of closing the inhaler.

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. 1 Hematemesis 2 Shortness of breath 3 Unilateral chest pain 4 Increased thoracic motion 5 Mediastinal shift toward the involved side

I put 2, 3, 5 Ans: 2, 3 With the reduction of surface area for gaseous exchange, the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Bloody vomitus is unrelated to pneumothorax. Decreased chest motion occurs because of failure to inflate the involved lung. The shift toward the unaffected side results from pressure with the pneumothorax.

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? 1 Inhales deeply through the mouthpiece, relaxes, and then exhales. 2 Inhales deeply, seals the lips around the mouthpiece, and exhales. 3 Uses the incentive spirometer for 10 consecutive breaths per hour. 4 Coughs several times before inhaling deeply through the mouthpiece.

I put 1 Ans: 3 Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.

The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? 1 Rhonchi 2 Wheezes 3 Fine crackles 4 Coarse crackles

I put 1 Ans: 4 A series of long, discontinuous low-pitched sounds similar to blowing through straw under water indicates coarse crackles. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways. Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction. Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. 1 Goggles 2 Surgical mask 3 Shoe covers 4 Gown 5 Gloves 6 N95 hepa mask

I put 1, 2, 4, 5 Ans: 2, 4, 5 A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving client care at the bedside.

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning? Select all that apply. 1 "Resonance indicates the presence of trapped air." 2 "Dullness can be percussed over a consolidated lung." 3 "Hyperresonance is characteristic of normal lung tissue." 4 "Tympanic notes over the lung usually indicate a large pneumothorax." 5 "Flatness percussed over the lung fields indicates massive pleural effusion."

I put 1, 2, 5 Ans: 2, 4, 5 Dullness can be percussed over an atelectatic lung or a consolidated lung. Tympanic notes over the lung usually indicate a large pneumothorax. Flatness percussed over the lung fields indicates massive pleural effusion. These statements made by the student nurse indicate effective learning. Resonance is characteristic of normal lung tissue. Hyperresonance indicates the presence of trapped air.

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? 1 Instruct the client to splint the wound with a pillow when coughing. 2 Place the client in the supine position and inspect the site of the incision. 3 Assess the intensity of the pain and administer the prescribed analgesic. 4 Call the healthcare provider immediately and then check for wound dehiscence.

I put 2 Ans: 1 Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the healthcare provider and then check for wound dehiscence.

A nurse is teaching a community health class about the risk factors for cancer. Which factor has the least influence in predisposing an individual to cancer of the larynx? 1 Air pollution 2 Heavy alcohol ingestion 3 Inadequate dental hygiene 4 Chronic respiratory infection

I put 2 Ans: 3 Inadequate dental hygiene may predispose a person to oral infections but is involved only remotely in laryngeal neoplasms because of the anatomic relationship of the oral cavity and the larynx. Irritation by air pollutants may initiate tissue changes that can lead to malignancy. Alcohol is an irritant that may initiate tissue changes that result in a malignant neoplasm. Tissue alterations caused by repeated microbiologic stress may result in a malignant neoplasm.

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding? 1 Changes in the chest x-ray findings 2 Sputum that contains particles of blood 3 Nasal discharge containing carbon particles 4 Changes in the arterial blood gases consistent with acidosis

I put 2 Ans: 3 Singed nasal hair and nasal discharges that contain carbon are warning signs of respiratory inhalation. Changes in chest x-ray findings are a late sign of respiratory problems. Sputum that contains particles of blood may be a sign of pneumonia or tuberculosis. Changes in arterial blood gases are late signs of respiratory problems.

During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. 1 Croup 2 Atelectasis 3 Cystic fibrosis 4 Bronchospasm 5 Pulmonary edema

I put 2, 3, 5 Ans: 2 & 5 The short, discontinuous, high-pitched sounds that sound like hair being rolled between fingers just behind the ear in the bilateral lower lobes indicate fine crackles. These sounds may be auscultated in clients with pulmonary disorders such as idiopathic pulmonary fibrosis, atelectasis, and pulmonary edema. Croup is a respiratory disorder characterized by a continuous musical or a crowing sound of a constant pitch. Cystic fibrosis is characterized by continuous rumbling, snoring, and rattling sounds from secretions obstructing large airways. Bronchospasms are characterized by continuous high-pitched, squeaking, or musical sounds caused by rapid vibration of bronchial walls.

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking? 1 Teach pursed-lip breathing. 2 Encourage the client to reduce emotional stress. 3 Obtain a referral to a smoking-cessation program in the community. 4 Suggest that the client limit smoking to one pack of cigarettes a day.

I put 3 Ans: 1 Limiting the number of cigarettes smoked daily may be an effective first step toward smoking cessation [1] [2]. An all-or-none approach often is not effective. The ultimate goal is to eliminate smoking entirely. Pursed-lip breathing improves exhalation of CO2, but it will not help the client stop smoking. Emotional stress may or may not be associated with the client's smoking; usually it is an addiction to nicotine that drives the need to smoke. The client needs to be motivated to stop smoking; a referral without a personalized discussion is not enough for an addicted smoker to pursue a smoking-cessation program.

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? 1 Mediastinal shift 2 Tracheal laceration 3 Open pneumothorax 4 Pericardial tamponade

I put 3 Ans: 1 Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? 1 Encourage range of motion to the client's arm on the affected side 2 Administer the prescribed cough suppressant at the prescribed times 3 Empty and measure the drainage in the collection chamber each shift 4 Apply clamps below the insertion site when getting the client out of bed

I put 3 Ans: 1 Range-of-motion exercises to the client's arm on the affected side promote maintenance of function in the arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. Drainage is marked with time taped on the side of the device. The closed system is not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be avoided because of the danger of precipitating a tension pneumothorax.

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? 1 Collect drainage 2 Ensure adequate suction 3 Maintain negative pressure 4 Sustain a continuance of the water seal

I put 3 Ans: 1 The chamber closest to the client in a three-chamber system [1] [2] is the first chamber; it collects drainage. Chamber 2 is the water seal that ensures that air does not enter the pleural space. Chamber 3 is the suction control chamber of the system. The third chamber in a three-chamber system is the suction regulator when it is attached to a source of suction. Chamber 1, the chamber closest to the client in a three-chamber system, does not maintain negative pressure. The second chamber is the water-seal chamber that prevents air from entering the client's pleural space.

Which action performed by the nursing student during the chest examination of a client needs correction? 1 Placing the stethoscope over bony prominences 2 Palpating two ribs inferiorly in the midaxillary line 3 Dividing the anterior and posterior lungs into thirds 4 Listening to at least one cycle of inspiration and expiration

I put 3 Ans: 1 The stethoscope should be placed over the lung tissue and not over bony prominences during chest auscultation. The nursing student should palpate the two ribs inferiorly in the midaxillary line and around the posterior chest. When documenting the location of lung sounds, the nursing student should divide the anterior and posterior lungs into thirds to describe the sounds. At each placement of the stethoscope, the nursing student should listen to at least one cycle of inspiration and expiration.

Three weeks after having a laryngectomy a client asks about what to do if the laryngectomy tube becomes dislodged. An appropriate nursing response is to instruct the client to take which action? 1 Notify the primary healthcare provider immediately 2 Reinsert another tube as soon as possible 3 Place a sterile gauze pad over the stoma 4 Perform rapid deep breathing

I put 3 Ans: 2 A permanent opening into the trachea is formed after two or three weeks; tube dislodgement is not an emergency, but another tube should be inserted. The client is in no immediate danger, and it is not imperative to notify the healthcare provider at once. Placing a sterile gauze pad over the stoma is not necessary. Gauze should not be placed over the stoma; inserting a new tube is best. Rapid deep breathing is not necessary.

A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. What assessment by the nurse is the best method for assessing this complication? 1 Percussing the neck and chest 2 Palpating the neck or face 3 Auscultating for abnormal breath sounds 4 Observing for asymmetry of chest movement

I put 3 Ans: 2 Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Percussion is not an appropriate method for assessment; breath sounds are not affected. Asymmetry of chest movements may occur because of the pneumothorax but is not indicative of subcutaneous emphysema.

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube? 1 Has an inner cannula 2 Is changed every week 3 Is cleansed once a day 4 Has a low-pressure cuff

I put 3 Ans: 4 A low-pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis. The tracheostomy tube can be a single-lumen tube or can have inner and outer cannulas. A tracheostomy tube does not have to be changed weekly. The tracheostomy should be cleaned every 8 hours and whenever necessary.

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm? 1 The residual capacity of the lungs has been increased. 2 Inspiration has been markedly prolonged and difficult. 3 The client has an increase in the vital capacity of the lungs. 4 Abdominal breathing is an effective compensatory mechanism and is spontaneously initiated.

I put 4 Ans: 1 Loss of elasticity causes difficult exhalation, with subsequent air trapping. Clients who have emphysema are taught to use accessory abdominal muscles and to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Expiration is difficult because of air trapping and poor elasticity. There will be decreased vital capacity. Diaphragmatic breathing is a learned mechanism that is beneficial.

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? 1 Hyperoxygenate with 100% oxygen before and after suctioning 2 Suction two or three times in quick succession to remove secretions 3 Use the technique of short, pushing movements when applying suction 4 Apply suction for no more than 10 seconds while inserting the catheter

I put 4 Ans: 1 Suctioning removes not only secretions but also oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after. Suction should be performed only as needed to maintain a patent airway; excessive suctioning irritates the mucosa, which increases secretion production. Short, pushing movements can cause tracheal damage. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting.

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's best response? 1 "Notify the respiratory therapist." 2 "Empty the fluid from the tubing." 3 "Decrease the amount of humidity." 4 "Document the output on the record."

I put 4 Ans: 2 Emptying the fluid from the tubing is necessary to prevent fluid from entering the trachea; some systems have receptacles attached to the tubing to collect fluid; others have to be temporarily disconnected while fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Decreasing the amount of humidity is unsafe; humidity is necessary to preserve moistness of the respiratory tract and to liquefy secretions. The amount of condensation is irrelevant to intake and output.

A nurse is involved in an international committee to address global health problems. What suggestion is most appropriate for the nurse to make to best meet the challenge associated with a potential emerging influenza pandemic? 1 Stockpile antibiotics. 2 Establish a global surveillance plan. 3 Limit vaccination programs to school-aged children. 4 Initiate vaccination programs during the months of August and September.

I put 4 Ans: 2 Surveillance and containment are the first lines of defense against outbreaks of infectious disease. While it is important to have adequate supplies of antibiotics to treat illness, antibiotics do not prevent illness; vaccines should be administered to protect vulnerable populations. Vaccines should be used to protect all vulnerable populations such as older adults, immunocompromised individuals, those with chronic medical conditions, those caring for individuals at high risk, and healthcare providers, not just children; some influenza vaccines are not administered to children younger than 5 years of age. Most vaccination programs inoculate clients during the months of October and November in preparation for the influenza season, which is generally from November through March.