Respiratory EAQ
A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 . Crackles 2 . Cyanosis 3 . Dyspnea 4 . Bradypnea 5 . Frothy sputum
1 . Crackles2 . Cyanosis3 . Dyspnea5 . Frothy sputum Crackles signify fluid in the alveoli because of increased capillary permeability associated with pulmonary edema. Cyanosis is evidence of inadequate oxygenation. Frothy sputum results because of the large amount of fluid in the lungs; it may or may not be blood tinged. Chest pain is not a symptom of acute pulmonary edema; this is associated with a pneumothorax. Dyspnea, not bradypnea, is associated with pulmonary edema.
Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action? 1. Auscultate the chest 2. Obtain the vital signs 3. Elevate the head of the bed 4. Position the client on the right side
3. Elevate the head of the bed Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be done eventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.
A client returns to the unit fully awake after a bronchoscopy and biopsy. Which action is priority? 1. Assess the presence of a gag reflex 2. Provide ice chips as a comfort measure 3. Encourage the client to cough frequently 4. Advise the client to stay flat for several hours
1. Assess the presence of a gag reflex Because of the administration of a local anesthetic during bronchoscopy, fluids and food should be withheld until the gag reflex returns to prevent aspiration. Ice chips must not be given until the gag reflex returns. Coughing should not be encouraged because it might initiate bleeding from the biopsy site. Lying flat will increase the risk for aspiration.
Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. What is the priority nursing intervention? 1. Turn the client onto the right side 2. Notify the healthcare provider immediately 3. Document the output as an expected finding 4. Irrigate the drainage catheter to ensure patency
2. Notify the healthcare provider immediately Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system; it functions via negative pressure, not gravity. Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. 1. Sharp chest pain 2. Acute onset of dyspnea 3. Pain in the residual limb 4. Absence of the popliteal pulse 5. Blanching of the affected extremity
1,2 Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.
After surgery, a client is extubated in the post-anesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. 1. Confusion 2. Hypocapnia 3. Tachycardia
1,2,3 Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.
In which positions should the nurse place a client who has just had a right pneumonectomy? 1. Right or left side-lying 2. High-Fowler or supine 3. Supine or right side-lying 4. Left side-lying or low-Fowler
3. Supine or right side-lying Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it may be tiring for a postoperative client. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump.
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1. A 59-year-old who had a knee replacement 2. A 60-year-old who has bacterial pneumonia 3. A 68-year-old who had emergency dental surgery 4. A 76-year-old who has a history of thrombocytopenia
1. A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client?
1. Notifying the Rapid Response Team 2. Reassuring the client and family members 3. elevate the head of the bed to help the client breathe easier 4. Prepare oxygen therapy and blood gas analysis 5. Monitoring and assessing for other changes When a client is admitted to the hospital with sudden onset of dyspnea and chest pain, the nurse should immediately notify the Rapid Response Team on a priority basis. Reassuring the client and the family members helps to stabilize the client. Then the nurse should elevate the head of the bed to help the client breathe easier. To prevent the severity of dyspnea, the client should be prepared for oxygen therapy and blood gas analysis. This should be followed by monitoring and assessing for other changes in the client.
The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? 1. Palpate around the tube insertion sites for crepitus 2. Auscultate the breath sounds for crackles and atelectasis 3. Observe the client for the presence of a barrel-shaped chest 4. Compare the length of inspiration with the length of expiration
1. Palpate around the tube insertion sites for crepitus Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.
A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? 1. Palpate the area around the tubes for crepitus 2. Clamp the chest tubes when suctioning the client 3. Empty the drainage chamber at the end of the shift 4. Change the client's dressing daily using aseptic technique
1. Palpate the area around the tubes for crepitus Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is palpated gently; this is referred to as crepitus. Hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system; otherwise, clamping the tube is not necessary. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. To minimize the risk of a pneumothorax, the dressing is not changed routinely.
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.Promote bed rest with raised head of bed. 2.Provide oxygen via nasal cannula. 3.Obtain blood specimens for C & S. 4.Administer prescribed antibiotic. 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 is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply. 1. Apathy 2. Dyspnea 3. Hemoptysis 4. Bronchial wheezes 5. Feeling of impending doom
2,3,5 Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus usually are apprehensive and hyperalert, not apathetic. Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders, such as asthma.
A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? 1. Administer continuous oxygen 2. Increase fluid intake to at least 2 L a day 3. Place the client in a high-Fowler position 4. Instruct the client to gargle deep in the throat using warmed normal saline
2. Increase fluid intake to at least 2 L a day Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take? 1. Obtain a prescription for a diuretic. 2. Have the client breathe into a rebreather bag. 3. Encourage the client to take deep, cleansing breaths. 4. Request a prescription for the administration of sodium bicarbonate.
3. Encourage the client to take deep, cleansing breaths. The client is in respiratory acidosis, probably caused by the depressant effects of an anesthetic or a compromised airway; deep breaths blow off CO2 and encourage coughing. Obtaining a prescription for a diuretic will not correct respiratory acidosis and may aggravate hypokalemia if present. Having the client breathe into a rebreather bag is the treatment for respiratory alkalosis; the client is in respiratory acidosis. Obtaining a medical prescription for the administration of sodium bicarbonate is not necessary if clearing of the airway corrects the problem.
A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period? 1. Maintaining T-tube drainage 2. Ensuring a pain-free experience 3. Encouraging coughing and deep breathing 4. Providing a heating pad for shoulder pain for 15 minutes hourly
3. Encouraging coughing and deep breathing Because of the high abdominal surgical incision, clients often avoid deep breathing and coughing and therefore need support and encouragement to accomplish these actions. Although maintaining T-tube drainage is important, encouraging coughing and deep breathing supports effective gas exchange, which is essential to prevent serious respiratory complications. Ensuring a pain-free experience may not be possible; some discomfort is expected. The nursing goal is to keep the client's pain at least at a tolerable level. Providing a heating pad for shoulder pain for 15 minutes hourly is employed for the shoulder pain caused by retained carbon dioxide after a laparoscopic cholecystectomy, not for an abdominal cholecystectomy.
A client is admitted to the post-anesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? 1. Raise the drainage system to bed level and check its patency 2. Clamp the tube when moving the client from the bed to a chair 3. Mark the time and fluid level on the side of the drainage chamber 4. Secure the chest catheter to the wound dressing with a sterile safety pin
3. Mark the time and fluid level on the side of the drainage chamber The fluid level and time must be marked so that the amount of drainage in the chest tube drainage system can be evaluated. The drainage system must be kept below chest level to promote drainage of the pleural space so the lungs can expand. Clamping the tube can produce backpressure, which may cause fluid to move into the pleural space from which it came, producing a tension pneumothorax. The catheter is secured by skin sutures, not to a dressing with a safety pin.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2 and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.
Which assessment finding is considered the earliest sign of decreased tissue oxygenation? 1. Cyanosis 2. Cool, clammy skin 3. Unexplained restlessness 4. Retraction of interspaces on inspiration
3. Unexplained restlessness Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.
A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. 1. Take short, frequent breaths 2. Exhale with the mouth open wide 3. Perform the exercises twice a day 4. Place a hand on the abdomen while feeling it rise 5. Hold the breath for several seconds at the height of inspiration
4,5 Abdominal breathing improves lung expansion because it makes the contraction of the diaphragm more efficient. Placing the hand on the abdomen to watch it rise provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Short breaths do not expand the lungs; deep, slow breaths should be encouraged. Exhalation with pursed lips, not with an open mouth, promotes exhalation of air from the lung and minimizes trapping of air in the alveoli. Breathing exercises should be performed at least every two hours.
A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment? 1. A client who is scheduled for a bronchoscopy 2. A client who is scheduled for a thoracentesis 3. A client with pleural effusion and decreased breath sounds 4. A client with acute asthma and 85% oxygen saturation
4. A client with acute asthma and 85% oxygen saturation A client with acute asthma may have low peripheral arterial oxygen saturation. Pulse oximetry results less than 86% requires immediate assessment and treatment. Scheduled bronchoscopies and thoracenteses do not require immediate action. Pleural effusions with decreased breath sounds are an issue, but this condition does not require immediate assessment.
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? 1. Take the client's vital signs. 2. Inform the healthcare provider. 3. Turn the client to the unaffected side. 4. Check the tube to ensure that it is not kinked.
4. Check the tube to ensure that it is not kinked. Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung re-expansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the healthcare provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? 1. Place the client in the supine position 2. Spread a clamp in the insertion site to hold the site open 3. Obtain a sterile Vaseline gauze to cover the opening 4. Cover the opening with the cleanest material available
4. Cover the opening with the cleanest material available This emergency situation requires covering the opening with the cleanest material available to prevent atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential for infection. Placing the client in the supine position is useless and will impair further the client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is taken to obtain the occlusive dressing.
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly? 1. Remains constant in the chest drainage chamber. 2. Is bubbling gently in the chest drainage chamber. 3. Is bubbling vigorously in the suction control chamber. 4. Rises in the tube of the water-seal chamber during inspiration.
4. Rises in the tube of the water-seal chamber during inspiration. Increased negative intrapleural pressure on inspiration causes the fluid to rise; a decrease in negative intrapleural pressure on expiration causes the fluid to fall. Remaining constant in the chest drainage chamber indicates that an obstruction is present in the drainage tubing or that the suction is too low; a slight increase in fluid should be evident in this chamber postoperatively. Bubbling gently in the chest drainage chamber indicates an air leak. If the water is bubbling vigorously in the suction control chamber, the suction is too high; bubbling should be gentle.
A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? 1. Tremors 2. Anasarca 3.Bradypnea 4. Tachycardia
4. Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurologic problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.
A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1.Obtain data about the client's history and physical status. 2.Insert an intravenous (IV) catheter to establish venous access. 3.Collect a sputum sample for culture and sensitivity. 4.Administer prescribed antibiotic intravenous piggyback. 5.Check peak and trough levels of the antibiotic.
1,2,3,4,5 Data collection precedes implementation. IV access is necessary for emergency administration of medications, but it cannot be initiated until the nurse has gathered some data (e.g., client may have a shunt for dialysis in an arm, which would preclude use of that arm). A sputum for culture and sensitivity should be obtained before antibiotic administration. The antibiotic should be started as soon as possible to treat the pneumonia. Peak and trough levels can be done only when the client has been receiving the medication.
A nurse witnesses a client collapse during a home care visit. Place the basic life support actions in the order they should be performed by the nurse. 1.Use physical and auditory stimulation to attempt to elicit a response. 2.Direct the client's spouse to call the emergency management system. 3.Listen and observe for spontaneous breaths. 4.Palpate to determine the presence of a carotid pulse. 5.Perform 30 chest compressions. 6.Open the airway with the head tilt-chin lift method and give two breaths.
1,2,3,4,5,6 Stimulation is required to determine if the person is actually unresponsive. Immediate activation of the emergency management system shortens response time and decreases mortality rate. Observing the rise of the chest and listening and feeling for the presence of breathing will determine if further action is needed. Palpation of the pulse determines if cardiac compression is needed. Begin 30 chest compressions to a depth of 2 inches (5 cm); this compresses the heart and pushes blood into the circulation. Opening the airway results in spontaneous breathing or prepares the person for two rescue breaths if needed. If two rescue breaths are given, they are alternated with chest compressions; rate is 30 compressions to two rescue breaths for a single rescuer, and 15 compressions to two rescue breaths for two rescuers.
The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. 1. Verify breath sounds. 2. Encourage deep breaths. 3. Observe for signs of pneumonia. 4. Ensure a chest x-ray is performed after the procedure. 5. Instruct the client to cough during the procedure.
1,2,4 Breath sounds should be verified in all lung fields after thoracentesis to rule out lung collapse. The client is encouraged to perform deep breaths to help expand the lungs. A chest x-ray should be obtained after the procedure to check for pneumothorax. Observing for signs of hypoxia and a pneumothorax is essential, but the signs of pneumonia may not be useful after thoracentesis. The client should be instructed not to talk or cough during the procedure because it may cause injury to the lungs.
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.
2. A chest x-ray will be performed to determine lung re-expansion. A chest x-ray should be performed to ensure and to document that the lung is re-expanded 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.
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
3. Normal acid-base balance 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.
A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? 1. An elevated pH, elevated PCO22 2. A decreased pH, elevated PCO23 3. An elevated pH, decreased PCO24 4. A decreased pH, decreased PCO2
3. An elevated pH, decreased PCO24 (In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated PCO2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO2 is respiratory acidosis. A decreased pH, decreased PCO2 is metabolic acidosis with some compensation.)
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).
3. HCO3 value is 50 mEq/L (50 mmol/L). 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.
A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? 1. Keep collection device attached to mechanical suction 2. Keep chest tube clamped distal to the water-seal chamber 3. Keep collection device below the level of the client's chest 4. Keep chest tube end covered with sterile gauze pads taped to the client
3. Keep collection device below the level of the client's chest The collection device must be kept below the level of the chest to prevent backflow of fluid into the pleural space. A chest tube clamped distal to the water-seal chamber is contraindicated. The chest tube should not be clamped because it may precipitate a tension pneumothorax. A chest tube end covered with sterile gauze pads taped to the client is contraindicated. There is no reason to disconnect the chest tube from the water-seal system; this will allow atmospheric air to enter the pleural space, causing a pneumothorax.
A client has a bronchoscopy in the ambulatory surgery unit. Which action should the nurse take to prevent laryngeal edema? 1. Place ice chips in the client's mouth 2. Offer liberal amounts of fluid to the client 3. Keep the client in the semi-Fowler position 4. Tell the client to suck on medicated lozenges
3. Keep the client in the semi-Fowler position With the head elevated, rather than horizontal or dependent, fluid will not collect in the interstitial spaces around the trachea. Placing ice chips in the client's mouth, offering liberal amounts of liquid, and telling the client to suck on lozenges may cause aspiration if the gag reflex has not returned.
A client who had surgery for a laryngectomy is returned to the surgical unit from the post-anesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? 1. Prone with the head turned to one side 2. Supine with the knees flexed at 10 degrees 3. Lateral with the head slightly elevated and flexed 4. Supine with the head in a hyperextended position
3. Lateral with the head slightly elevated and flexed The lateral position facilitates drainage of secretions from the mouth and respiratory passages, reducing the risk of aspiration. Slight elevation of the head decreases edema, promotes drainage, and facilitates respirations. Slight flexion of the head prevents strain on the suture line. The prone position with the head turned to one side will increase edema, stasis of drainage, obstruction of the airway, and tension on the suture line. The supine position with the knees flexed at 10 degrees will increase edema and stasis of drainage and may cause obstruction of the airway; the legs should be extended to reduce venous stasis and the risk of thrombophlebitis. The supine position will increase edema and stasis of drainage and may cause obstruction of the airway; hyperextending the head will cause tension on the suture line and should be avoided.
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1. Strip the chest tube periodically. 2. Administer the prescribed cough suppressant at the scheduled times. 3. Empty and measure the drainage in the collection chamber each shift. 4. Keep the drainage system lower than the level of the client's chest.
4. Keep the drainage system lower than the level of the client's chest. The drainage system is kept below the chest to allow gravity to drain the pleural space. The chest tube should not be stripped because this action can cause negative pressure and damage lung tissue. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help re-expand the lung. The closed system is not entered for emptying; when full, the entire device is replaced.
A client is transferred from the post-anesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort? 1. Sims 2. Lateral 3. Orthopneic 4. Semi-Fowler
4. Semi-Fowler The semi-Fowler position helps maintain the head and neck in functional alignment and facilitates respirations because the abdominal organs are not pressing against the diaphragm, which allows the thoracic cavity to expand without resistance. The Sims position will place tension on the operative site because the head must be turned to the side. The lateral position inhibits respiratory excursion because the abdominal organs press against the diaphragm, and full expansion of the lung on the side on which the client is lying is inhibited. The orthopneic position may cause flexion of the neck, which may place tension on the suture line.
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."
I should take aspirin if I experience bleeding. 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.
While performing a respiratory assessment of a client with pneumonia, a nurse hears these sounds. What should the nurse document in the client's medical record?
Pleural friction rubs Pleural friction rubs are creaking or grating sounds caused by roughened, inflamed pleural surfaces rubbing together. They are associated with pleurisy, pneumonia, or a pulmonary infarct and can be heard during inspiration, expiration, or both. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur due to obstruction of large airways with secretions. Fine crackles are a series of short-duration, discontinuous, high-pitched sounds caused by rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open. They are heard just before the end of inspiration. Coarse crackles are series of long-duration, discontinuous, low-pitched sounds associated with pulmonary edema or pneumonia with severe congestion. They sound like air is blowing through a straw underwater.
