Respiratory Content Post Test- HURST

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE? Select All That Apply 1. Drink plenty of fluids on a daily basis. 2. Stop and move around every 4 hours when taking a long trip. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

1, 3, 4, 5 Rationale 1., 3., 4., & 5. Correct: In order to get this question correct, you must first consider some of the risk factors for developing a DVT and PE. Some causes include: dehydration, venous stasis from prolonged immobility or surgery, obesity, birth control pills, clotting disorders, and heart arrhythmias like A-Fib. Therefore preventive measures would include such things as hydration by increasing fluid intake, prevention of stasis by isometric and stretching exercises of the feet, knees, and hips every 2 to 4 hours, prevention of obesity, and walking around at least 4 to 6 times per day. 2. The client does need to stop when traveling long distances, but it needs to be done more often than every 4 hours. This client has a history of DVT and PE, so it is very important that the client stop and move around at least every 2 hours.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select All That Apply 1. Shortness of breath 2. Decreased heart rate 3. Wheezing in the affected area 4. Chest pain 5. Cough 6. Subcutaneous emphysema

1, 4, 5, 6 Rationale 1.,4.,5., & 6. Correct: With a hemothorax, we recall that blood has accumulated in the pleural space, and with a pneumothorax, we know that it is air that has accumulated in the pleural space. The presence of either of these causes the lung to collapse. The signs that the nurse expects to see includes shortness of breath, chest pain, and cough. We may also see subcutaneous emphysema as the air that escaped from the lung becomes trapped in the surrounding tissues. 2. Incorrect: What happens to gas exchange when there is a hemothorax or a pneumothorax? That's right! It decreases. When hypoxia is present, the body responds by increasing the heart rate. Therefore, we would not expect the heart rate to be decreased in this situation. 3. Incorrect: Wheezing occurs when air tries to get through narrowed passages. With a hemothorax or pneumothorax, the lung sounds will be diminished over the affected area where the lung has collapsed.

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? Choose One 1. Administer high flow O2 per face mask. 2. Remove the occlusive dressing. 3. Notify the healthcare provider. 4. Initiate rapid IV resuscitation.

2 Rationale 2. Correct: Based on these signs and symptoms, we recognize that the client has developed a tension pneumothorax due to the occlusive dressing not only preventing air from getting in, but not allowing the air to escape. Therefore, management of this emergency situation would be the nurse's priority. Removal of the occlusive dressing would allow the air to escape and should help reduce the pressure that is causing the mediastinal shift. Needle decompression may also be needed to relieve the tension pneumothorax. If available, a good option for covering an open or "sucking" chest wound would be a petroleum gauze dressing which would be taped down on only three sides. This creates a flutter valve mechanism that allows air to escape but prevents air from re-entering through the open wound. 1. Incorrect: Although oxygen is used in clients experiencing hypoxia, it would not help to relieve or fix the tension pneumothorax. 3. Incorrect: This is an emergency and you, as the nurse, should recognize that the occlusive dressing has been trapping the air inside the chest and has created an emergency. You should carry out the intervention that you know will help to relieve the pressure that is building up as a result of air trapping in order to prevent further deterioration of the client's condition. Therefore, calling the healthcare provider first would be a delay of emergency care. 4. Incorrect: Did you see the word "deteriorating" and think shock and fluid resuscitation? The problem here is the trapping of air that is causing the tension pneumothorax. Administering IV fluids will not help to fix the problem.

What is the best position for the nurse to place a client for a thoracentesis of the right lung? Choose One 1. Lying supine with pillow removed and head of bed flat 2. Sitting on side of bed and leaning over the bedside table 3. Lying on the right side with the head of bed at 45 degrees 4. Lying supine with the left arm raised over the head

2 Rationale 2. Correct: For maximum accessibility for the thoracentesis to be performed, the client should be positioned in a sitting position on the side of the bed, leaning over a bedside table, with arms propped on pillows and the feet supported. If the client is not able to sit up, the alternative position would be to lie on the unaffected side with the head of bed elevated 45 degrees. 1. Incorrect: The approach for a thoracentesis is generally a posterior approach, so the supine position would not be optimal. Also, if a client has a respiratory problem requiring a thoracentesis, the client may experience increased respiratory distress if placed in a supine position. You would never want to place a client in a position that would increase the respiratory effort or cause distress. 3. Incorrect: If the client is unable to sit up on the side of the bed, it is acceptable to be in a side lying position with the head of bed elevated 45 degrees. However, the client should be placed on the unaffected side, which in this case would be the left side. In this client, the right side is the affected side and should be in the superior position. 4. Incorrect: The best position is sitting up, leaning over the bedside table, with arms resting on pillows and the feet supported. The alternative position is side lying, with the head of bed elevated. The supine position is not a position of choice but may have to be used under certain circumstances. If placed in a supine position, the arm on the affected side would be placed over the head. In this case, the right arm would need to be raised, not the left arm.

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for further teaching? Choose One 1. "I will take deep breaths using my incentive spirometer every 2 hours." 2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 3. "I will talk to my healthcare provider before taking the narcotic pain medicine that I currently have at home." 4. "I will notify my healthcare provider if I develop any change in my respirations or secretions."

2 Rationale 2. Correct: Immobilizing, and therefore restricting the chest wall movement, with binders and straps is not recommended as it leads to shallow breathing, atelectasis, and pneumonia. The client should be taught to use the hands to support the injured area. 1. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Incentive spirometry is used to help prevent respiratory complications such as pneumonia and respiratory acidosis. 3. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Clients with rib fractures are generally prescribed non-narcotic analgesics. This is done to avoid narcotics suppressing the respirations even more than what occurs with the reluctance to deep breathe associated with the painful rib fractures. Don't you agree that the client needs to deep breathe? Some clients may have other conditions being treated with narcotic pain medications. Before continuing these at home, the client should discuss this with the healthcare provider. If the pain is severe, a nerve block by anesthesia may be needed to facilitate deep breathing and coughing. 4. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Do you recall some of the possible complications associated with rib fractures? They include pneumonia, respiratory acidosis, pneumothorax, and hemothorax. Therefore, the client should notify the healthcare provider if respiratory difficulty develops, secretions increase or change color, cough develops or worsens, or other respiratory symptoms develop.

Assessment of a trauma client in the emergency department reveals paradoxical chest wall movement, respiratory distress, cyanosis, and tachycardia. The family is asking why the client needs positive end-expiratory pressure (PEEP). What should the nurse inform them regarding the rationale for this treatment? Select All That Apply 1. Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath. 2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 4. Allows for positive pressure to be applied continuously during inspiration and expiration. 5. It is less invasive and does not require the client to be on the ventilator.

2, 3 Rationale 2., & 3. Correct: I hope that you were able to recognize that the signs and symptoms are characteristic of a flail chest. This occurs with multiple rib fractures. The client will have pain, be anxious, and short of breath. The classic sign of a flail chest is the paradoxical (see-saw) chest movement in which the affected part of the chest sucks inwardly on inspiration and puffs out on expiration (opposite of what the normal side is doing). Dyspnea, cyanosis, and tachycardia are also generally seen. So, what is done about this unstable chest? PEEP may be used because it helps to improve gas exchange and decreases the work of breathing. As it exerts pressure in the lungs, it also facilitates the expansion and realignment of the ribs so that they can start growing back together. 1. Incorrect: The ventilator exerts the positive pressure down into the lungs at the end of expiration to keep the alveoli open. 4. Incorrect: Do you see the word "continuously"? This describes continuous positive airway pressure (CPAP). This is often used for individuals with sleep apnea and infants with underdeveloped lungs. 5. Incorrect: With PEEP, the client is on the ventilator.

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? Choose One 1. Insertion of a chest tube in the 7th intercostal space 2. Immediate removal of client from the ventilator 3. Needle decompression in the right 2nd intercostal space 4. Emergency thoracentesis of the left lung

3 Rationale 3. Correct: Did you recognize the signs of a tension pneumothorax? This client may have developed this because of a high PEEP level and/or compromised lung status combined with mechanical ventilation. Regardless of the cause, this is an emergency situation and the initial treatment involves the insertion of a large bore needle into the 2nd intercostal space, midclavicular line of the affected side. In this case, you should recognize that the absence of breath sounds on the right side indicate that the problem is on the right side. Needle decompression is done to release the pressure that is building up in the pleural space and causing the organs and vessels to be compressed. The mediastinal shift occurs toward the opposite (left) side. The client will most likely have a chest tube inserted on the right side, but the initial life saving measure for this would be the needle decompression. 1. Incorrect: What did you learn that is being removed when a chest tube is inserted low in the chest wall? That's right! Fluid. In this case, your clues were that the client was on mechanical ventilation and suddenly developed signs and symptoms of a tension pneumothorax. That means that air is accumulating and causing the problem. We need to remove this air that is compressing the vessels and causing decreased cardiac output. 2. Incorrect: This is a safety issue! Would you turn off a ventilator of a client that is needing this for ventilation ("artificial breathing")? No! You must deal with the problem and decompress the air that is accumulating in the pleural space. 4. Incorrect: The problem is on the right side. There is no need for a thoracentesis on the left side.

The nurse is caring for a surgical client who developed a pulmonary embolus (PE). Which diagnostic test would be the most sensitive for providing a definitive diagnosis for a PE? Choose One 1. D-dimer 2. Pulmonary function test 3. Pulmonary angiography 4. Chest X-ray

3 Rationale 3. Correct: Pulmonary angiography is the most sensitive and specific test for a PE. However, since it is very expensive and invasive, the computerized tomography angiogram (CTA) is the most frequently used test to diagnose a PE. 1. Incorrect: The D-dimer will be increased if a pulmonary embolism is present. However, since the client had surgery, you know that the D-dimer will be increased already because it simply tells if a clot is located anywhere in the body. It is not specific to clots in the lungs. 2. Incorrect: Pulmonary function tests provide information about how well the lungs are working. Various aspects such as lung volume, lung capacity, gas exchange, and rates of air flow can be determined. Although these help diagnose a lung problem, they are not specific to diagnosing a pulmonary embolism. 4. Incorrect: Chest x-rays are not very sensitive nor specific for diagnosing pulmonary embolisms in clients. Although clots do not show up on the x-ray, other findings that are suggestive of a PE may be found to indicate the need for further testing.

A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? Select All That Apply 1. Continuous bubbling is occurring in the suction control chamber. 2. Intermittent bubbling is noted in the water seal chamber. 3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 4. Slight fluctuations of water level in water seal chamber with respirations. 5. 190 mL of drainage noted in drainage collection chamber at 8 PM.

3, 5 Rationale 3. & 5. Correct: Do you see the problem with the bedside table? Yes! It's too high! The chest tube system should always be kept below the level of the chest to prevent backflow of drainage or air into the pleural space. You want to promote gravity drainage. The next problem that we see is excessive drainage. The chest tube was inserted at 5 PM and the client was admitted to the unit 2 hours later. The amount of drainage at upon arrival at 7 PM was 80 mL. At 8 PM, there was 190 mL of drainage. This is 110 ml of drainage in one hour. Drainage of 100 mL or greater any hour after the first hour is considered excessive. The healthcare provider would need to be notified of this amount of drainage. 1. Incorrect: Gentle, continuous bubbling in the suction control chamber is normal. 2. Incorrect: Intermittent bubbling in the water seal chamber when the client coughs, sneezes, or exhales is considered normal. 4. Incorrect: A slight rise and fall (fluctuation) of the water in the water seal chamber as the client breathes is called tidaling and is normal.

The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action? Choose One 1. Clamp the chest tube closest to the chest wall. 2. Increase the water level in the water seal chamber. 3. Have the client take a deep breath and do valsalva maneuver. 4. Notify the healthcare provider.

4 Rationale 4. Correct: Continuous bubbling in the water seal chamber indicates that there is an air leak in the system. The healthcare provider should be notified. The healthcare provider may prescribe for the tube to be clamped at intervals along the tube for only a few seconds to determine the location of the air leak, but clamping of the tube should never be done without a prescription. 1. Incorrect: Clamping of the tube should never be done without a prescription. Clamping a chest tube can lead to a tension pneumothorax, which can be a life-threatening situation. 2. Incorrect: Increasing the water level in the water seal chamber will not help the air leak problem. Also, the levels of water for the water seal chamber and the suction control chamber are prescribed by the healthcare provider and should be maintained at the prescribed levels. 3. Incorrect: Will taking a deep breath and performing the Valsalva fix an air leak in the tube? No. So you need to notify the healthcare provider. Later, when it is time for the chest tube to be removed, you should instruct the client to take in a deep breath and do valsalva maneuver, but doing that in this situation will not help fix the problem.