respiratory EAQ

A client with a diagnosis of tuberculosis is receiving isoniazid as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?

Yellow sclera

The nurse is providing care during the immediate postoperative period for a client that had a radical neck dissection. What is the best method to assess for stridor?

listen with a stethoscope over the trachea 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.

What is the priority nursing action when caring for a client receiving nitroglycerin for the treatment of angina?

Asking the client to sit or stand slowly Nitroglycerin is a potent antihypertensive and antianginal medication. The nurse should instruct the client to sit and stand slowly after taking the medication to prevent orthostatic hypotension. After ensuring the client's safety, the nurse should monitor the urine output. A headache is a common side effect of nitroglycerin. The client should have a tingling sensation after taking the nitroglycerin, which ensures that the medication is potent.

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus?

Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. A forearm laceration, migraine headache, or a respiratory infection does not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

A nurse is teaching a client with tuberculosis about recovery after discharge from the hospital. Which instruction is the priority?

Consistently taking prescribed medication Tubercle bacilli are particularly resistant to treatment and can remain dormant for prolonged periods; medication must be taken consistently as prescribed for prolonged periods. Although having sufficient rest is important, microorganisms must be eliminated by the use of medication. Although getting plenty of fresh air is important, microorganisms must be eliminated by the use of medication. Although changing the current lifestyle is important, microorganisms must be eliminated by the use of medication.

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." What should be the nurse's initial response?

Discuss the client's concerns Addressing the client's feelings and then exploring preventive measures should reduce anxiety. The risk of a pulmonary embolus is a real concern, not a misconception, associated with thrombophlebitis. Explaining measures to prevent a pulmonary embolus is not the client's concern; this response does not address the client's feelings concerning the risk of sudden death. Teaching recognition of early signs and symptoms of pulmonary emboli disregards the client's expressed fears and may increase anxiety.

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation?

Early unexplained restlessness Early unexplained restlessness is a central nervous system sign of inadequate oxygenation that may be observed in the client with a respiratory disorder. Late cyanosis is a cardiovascular sign of inadequate oxygenation. Early tachypnea and late use of accessory muscles are signs of inadequate oxygenation associated with the respiratory system.

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?

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.

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). What should the nurse monitor for when assessing for this complication?

Elevated hemoglobin The body attempts to compensate for decreased oxygen to tissues by increasing the number of blood cells, the oxygen-carrying component of the blood. With polycythemia, the skin, especially the face, appears flushed, not pale. Dyspnea on exertion is not specific to polycythemia; there is more than one cause of dyspnea on exertion. The hematocrit is increased with polycythemia.

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, what is the most important nursing intervention?

Ensure nothing by mouth (NPO) until the gag reflex returns Ensuring nothing by mouth until the gag reflex returns prevents aspiration. Although assessing for signs of hemoptysis is important because hemoptysis can occur after these procedures, it is not the priority. The supine position can promote aspiration. Checking for level of consciousness is unnecessary after this procedure.

A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include?

Helping the client set a date to stop smoking Setting a realistic target date to stop smoking can be motivating because it provides time to gather personal resources while committing to a specific time frame. The American Heart Association and the American Lung Association are appropriate agencies for referral, not the American Red Cross. Increasing eating may result in a weight gain that can precipitate reestablishing the habit of smoking to return to the former weight. The client should be called every three to five days, not weeks, after the target date for optimum support.

A client, appearing anxious, has a respiratory rate of 40 shallow breaths per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. The nurse concludes that the client's complaints probably are related to what?

Hyperventilation The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these adaptations; if uninterrupted this can result in respiratory alkalosis. Eupnea is normal, quiet breathing; the client has shallow, rapid breathing. Kussmaul's respirations are deep, gasping respirations associated with diabetic acidosis and coma. These adaptations are related to a decreased carbon dioxide level in the body.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure?

I wake up at night short of breath. Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile, snoring loudly, and shoes seeming larger are not related to heart failure.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. What does the nurse plan to do to decrease the amount of secretions retained?

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 and when prescribed. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx. Placing the client in a high Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity.

The parents of a school-aged child with cystic fibrosis tell the nurse that they have changed to natural pancreatic enzymes because of money issues. What is an appropriate response by the nurse?

Natural enzymes are not as effective as the brand-name product Natural pancreatic enzymes are not considered adequate in children with cystic fibrosis because of the bioavailability of the enzymes. Pancreatic enzyme supplementation is a lifelong treatment for cystic fibrosis. All medications have side effects, and pancreatic enzymes should be taken with meals. Giving twice as many natural enzymes does not constitute accurate dosing.

The nurse is caring for a client that has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?

Night sweats and blood-tinged sputum Blood-tinged sputum, in the absence of pronounced coughing, often is the presenting sign of TB; diaphoresis at night is a later sign. Recurrent fever is present; frothy sputum occurs with pulmonary edema. A productive cough occurs with TB. A productive cough occurs with TB, but engorged neck veins occur with heart failure.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs; as sodium is retained, potassium is excreted.

Clients are encouraged to perform deep-breathing exercises after most types of surgery. The nurse reminds clients that the reason for these exercises is to help do what?

Prevent the buildup of carbon dioxide in the body Retention of carbon dioxide in the blood lowers the pH, causing respiratory acidosis; deep breathing maximizes gaseous exchange, ridding the body of excess carbon dioxide. Deep breathing improves oxygenation of the blood, but it does not stimulate red blood cell production. Although regular deep breathing improves the vital capacity of the lungs, residual volume is unaffected. Deep breathing increases, not decreases, the partial pressure of oxygen.

A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply.

Providing mechanical ventilation Administering sodium bicarbonate The use of mechanical ventilation is necessary if the metabolic acidosis is severe and the client is in comatose stage. The administration of sodium bicarbonate can also be used to treat metabolic acidosis. If the client was conscious, then the nurse could help the client breathe into a paper bag to increase CO 2 levels. In respiratory acidosis, not respiratory alkalosis, CPAP is used to promote exhalation of carbon dioxide. The intermittent positive pressure breathing would be beneficial in respiratory acidosis, not respiratory alkalosis.

A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, the nurse recalls that homeless persons are at risk for what?

Tuberculosis Medically underserved clients, such as the homeless, clients who are alcohol or drug dependent, and those who have human immunodeficiency virus (HIV) infections are at risk for developing tuberculosis. Being homeless does not increase a person's risk for developing prostatitis, osteoarthritis, or diverticulosis.

client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. What should the nurse suggest that the client do?

Use a humidifier in the bedroom A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early morning congestion.

A nurse reviews the use of an incentive spirometer with a client. What client action indicates the need for further instruction?

Blowing vigorously into the mouthpiece The client should exhale before inhaling slowly and deeply through the spirometer to maximize lung expansion. Sitting in a chair will facilitate diaphragmatic excursion and help maximize lung expansion. Coughing will help remove secretions mobilized by use of a spirometer. The client's lips must form a seal around the mouthpiece to measure the volume of air inhaled.

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140 mm Hg Systolic blood pressure associated with stage 1 hypertension is between 140 and 159 mm Hg. Optimal systolic blood pressure is less than 120 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg.

A nurse is assisting the primary health-care provider in examining a client. The primary health-care provider confirms that the client has obstructive sleep apnea. Which physical symptoms does the nurse expect the client to report? Select all that apply.

Insomnia Morning headaches Frequent awakening at night Insomnia, morning headaches, and frequent nighttime awakening are physical clinical manifestations of obstructive sleep apnea. Therefore the nurse anticipates that the client will report these symptoms. Fatigue and decreased motivation may be expected as well, but these are are psychological signs of sleep deprivation.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner?

Erythropoietin (Procrit) 6000 units subcutaneously TIW "TIW", indicating three times a week is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation "AM" for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of "ac" (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of just "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation "Sub-Q", indicating the subcutaneous route is an acceptable abbreviation. "BID," indicating twice a day, is an acceptable abbreviation. "International units" must be completely spelled out instead of just "IU" because it may be mistaken as a four.

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. The nurse concludes that the altered blood levels are caused by what?

Increased erythrocyte production as a result of chronic hypoxia Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit.

An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response?

"Avoid putting your hands near your nose and mouth." Transmission of microorganisms via the hands is one of the most common ways pathogens are transmitted from one person to another. Avoiding putting hands near the nose and mouth interrupts the chain of infection at the portal of entry phase. Staying away from preschool and school-age children is unnecessary and could cause social isolation. However, exposure to these children when they have an active infection should be avoided if possible. Precautions can be taken when around children (e.g., washing the hands, avoiding exposure to nasal and oral secretions). Wearing a sweater under the coat when going outside in cold weather will not limit the exposure to pathogenic microorganisms. However, it may make the person more comfortable because older people have less subcutaneous fat and can be more sensitive to cold environmental temperatures. Colds are caused by viruses; an aspirin will not eliminate these microorganisms. In addition, it is not within the role of a nurse to prescribe medications, even if they are over-the-counter medications.

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role?

"I will take clients' vital signs after their procedures are over." Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' IVs that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. Helping by giving medications to clients who are slow in taking pills should be performed by registered professional nurses or licensed practical nurses, not UAPs.

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.

Bed rest Oxygen via nasal cannula Specimens for C&S Administration of an antibiotic The client's respiratory status is the priority; bed rest reduces oxygen demands and the administration of oxygen increases oxygen to the alveolar capillaries; specimens for culture and sensitivity must be obtained before the administration of antibiotics, which prevents false microbiologic interpretation caused by the effect of the antibiotic.

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe?

Calcium These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.

The nurse auscultates fine crackles in a client who has been in respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

What is the priority goal for a client with asthma who is being discharged from the hospital?

Demonstrates use of a metered-dose inhaler Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have before discharge. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Not all asthma is associated with food allergies.

A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations?

Hyperventilation The client is hyperventilating and is blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted, this can lead to respiratory alkalosis. Shortness of breath is a sign of dyspnea. There is no evidence that the client is having difficulty breathing. Kussmaul respirations are deep, gasping respirations associated with diabetic acidosis and coma, not hyperventilation associated with anxiety. These clinical manifestations are related to a decreased, not increased, carbon dioxide level in the body.

A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further information?

I'm upset to know that the tumor may metastasize to my bones." Osteogenic sarcoma is the most common and most often fatal primary malignant bone tumor. It has a high mortality rate because it often is diagnosed after it has metastasized to the lung . Pain may or may not be associated with a primary site or sites of metastasis. Pain that does occur may range from mild and occasional to constant and severe. "I can have metastasis to other parts of my body besides the lung" is a true statement, and further teaching is not necessary. Because the tumor may continue to metastasize, planning for the future (e.g., medical treatment, palliative interventions) should be discussed with the client, family, health care provider, and other support systems.

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority?

Immediately contact the primary health care provider The observation may be indicative of bleeding and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing only to monitor the client is unsafe. Monitoring vital signs every hour for four hours is a potentially life-threatening situation; the health care provider should be notified immediately. Increasing the coughing and deep breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism

Obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.

A client's cells are deprived of oxygen during a cardiac arrest. What medication should the nurse be prepared to administer?

Sodium bicarbonate In the absence of oxygen, the body derives its energy anaerobically; this results in buildup of lactic acid. Sodium bicarbonate, an alkaline drug, will help neutralize the acid, raising the pH. Insulin is used to treat diabetes; it lowers blood sugar by facilitating transport of glucose across cell membranes. Calcium gluconate is used to treat hypocalcemia. Although potassium is essential for cardiac function, it will not correct acidosis. With acidosis, serum hydrogen ions will exchange with intracellular potassium, leading to a temporary hyperkalemic state; therefore, potassium chloride is contraindicated until acidosis is corrected.

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately?

Suction the tracheostomy. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube and ties or a healthcare provider changing the tracheostomy tube.

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client?

Suctioning the tracheostomy tube whenever necessary Secretions are increased because of alterations in structure and function; a patent airway must be maintained. The client cannot whisper because air no longer exits the lungs by passing through the vocal cords. Initially nonverbal and written forms of communication are encouraged. The orthopneic position may cause neck flexion and block the airway. The outer tracheostomy tube is not removed because the stoma may close.

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply.

Airway Breathing Circulation Exposure or environmental control The primary survey focuses on airway, breathing, circulation (ABC), and environmental control. These are surveyed during emergency assessments in a primary survey to identify life-threatening conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating family presence are performed in a secondary survey of emergency assessment followed by a primary survey.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority

Apply a petroleum gauze dressing over the site A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment.

What nursing action will limit hypoxia when suctioning a client's airway?

Apply suction only after catheter is inserted The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention?

Asses Vital Signs Assessment is the first step of the nursing process and vital signs provide vital information about the client's cardiopulmonary status. Although inserting a saline lock may be done, it is not the priority. Although placing the client on oxygen may be done, it is not the priority. Administration of oxygen may alter the client's baseline vital sign results. Although drawing blood for troponins may be done, it is not the priority.

A client is receiving morphine sulfate for severe metastatic bone pain. What should the nurse do to prevent complications from a common, serious side effect of morphine?

Assess for altered breathing patterns Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. The nurse concludes that the severe dyspnea probably is caused by what?

Bronchial obstruction or pleural effusion Proliferation of malignant cells may obstruct the bronchial tree or foster development of exudate in the pleural space, decreasing the availability of oxygen and increasing retention of carbon dioxide. A tumor of the lung does not cause abdominal distention or pressure. Fluid retention as a result of renal failure is not associated with cancer of the lung. Although anxiety associated with pain may increase the respiratory rate, it will not cause difficulty with breathing

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client?

Carbon dioxide retention loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis). Tissue necrosis results from localized tissue anoxia and will not cause the systemic response of respiratory acidosis. Normal oxygen saturation of hemoglobin is 95% to 100%, so this is not a sign of acidosis. An increased respiratory rate may lead to respiratory alkalosis.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear?

Crackles Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

A health care provider prescribes oxygen given in low concentration rather than in high concentration to a client with chronic obstructive pulmonary disease (COPD). What does this prevent?

Depression of the respiratory center Some clients with COPD must be given only low concentrations of oxygen; decreased oxygen blood level is a major stimulus for breathing for these clients. Prolonged hypoxia stimulates erythrocyte production; the goal of therapy is to relieve hypoxia. The pressure, rather than the concentration, at which oxygen is administered increases the risk of emphysematous bullae rupture. To prevent drying effects on secretions and the mucosa, oxygen may be humidified.

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

Diminished breath sounds on auscultation Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema.

The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe how often?

Every hour for the first 24 hours and then every 2 hours Excessive endotracheal secretions after a pneumonectomy require coughing routines that are effective but not exhausting. Every 15 minutes for the first 24 hours and then every 2 hours, and every 30 minutes for the first 24 hours and then every 2 hours are too exhausting. Every 2 hours for the first 24 hours and then every 3 hours is not specific for a client who has had a pneumonectomy. Every hour for the first 24 hours and then every 2 hours would be appropriate for this client.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

I get a sharp, stabbing pain when I take a deep breath Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.

A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment?

Increase Breath sound The chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function. Increased respiratory rate may be a sign of pain, respiratory obstruction, or bleeding. Crepitus detected on palpation of the chest indicates that air has entered the subcutaneous tissue (subcutaneous emphysema). Constant bubbling in the drainage collection chamber indicates a probable leak in the drainage system.

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?

Instruct the client to splint the wound with a pillow when coughing 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 health care provider and then check for wound dehiscence.

Several days after a client had a total laryngectomy, the health care provider prescribes a progressive diet as tolerated. What should the nurse do?

Keep suction apparatus readily available in case excessive respiratory secretions occur. Initial attempts at oral feeding may cause a choking feeling that may produce severe coughing that raises secretions. Effective coughing is difficult because with a laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive secretions may block the airway and must be removed by suctioning. Swallowing does not have an adverse effect on the suture line; a nasogastric tube is not used because it can traumatize the suture line. A progressive diet is started with liquids, not pureed foods. Airway patency is the priority, not administering medication for pain.

A client is diagnosed with tuberculosis associated with human immunodeficiency virus (HIV) infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started?

Liver function studies Antitubercular drugs, such as isoniazid and rifampin are hepatotoxic. Pulmonary function studies, electrocardiogram, and echocardiogram are not related to the administration of antitubercular drugs or to their side effects. The white blood cell count is expected to be higher in the presence of infection, but with acquired immunodeficiency syndrome (AIDS) the WBC count will be less than 2500/cm3, and helper T cells will number less than 200 mm3; the T4/T8 ratio will be 1:2. These tests will not provide information relative to starting antitubercular therapy or to its side effects.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. What are they best described as?

Moist rumbling sounds that clear after coughing Coarse rhonchi, particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.

A thallium scan is prescribed for a client with a history of chest pain. What information should the nurse include when explaining the purpose of the test to the client?

Myocardial muscle viability is determined. Myocardial muscle viability is determined by the viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope. The scan monitors action of the heart valves available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole are determined by cardiac angiography. Identifying the adequacy of electrical conductivity is determined by an electrocardiogram (ECG).

A nurse who is caring for a client after head and neck surgery is concerned with the client's anger and depressive episodes about the effects of surgery. Which action indicates the client is reaching acceptance?

Performing self-care of the tracheal stoma The best indicator of acceptance is when the client begins to participate in self-care. Smiling and becoming more extroverted does not indicate acceptance and may be an act of pretended courage. Ambulating in the hall and sitting in the lounge does not indicate acceptance and may be an attempt to relieve boredom. Allowing a family member to participate in care does not indicate acceptance and may indicate dependence.

What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?

Placing a tracheostomy unit by the bedside The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is what?

Pulmonary embolism pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow. The occurrence of pneumonia is rare because of early activity after surgery. In addition, the operative area is not in proximity to the diaphragm and lungs; therefore, it does not impede deep breathing. Postoperative hemorrhage with hip surgery is rare because bleeding at the operative site is not covert. The incidence of wound infection is no greater than with other postoperative clients.

The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary?

Reduced oxygen levels can stimulate dysrhythmias. Inadequate oxygenation can cause premature ventricular complexes. Although the client will have closed-chest drainage in place, it does not explain why adequate oxygenation is important. Hypoxia can precipitate respiratory acidosis; hyperventilation causes respiratory alkalosis. Postoperative pain can increase the respiratory rate; increased respiratory rate does not increase the pain level.

A client recovering from abdominal surgery is encouraged to turn from side to side and engage in deep-breathing exercises. What complication is the nurse trying to prevent?

Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what?

Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

A client is receiving oxycodone postoperatively for pain. The health care provider's prescription indicates that the dose should be administered every three hours for eight doses. What should the nurse assess before administering each dose of oxycodone?

Respiratory rate and level of consciousness Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone.

What does the nurse assess for to evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax?

Return of breath sound The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase. Constant bubbling in the water-seal chamber indicates that there is a leak in the closed chest drainage system. Bubbling may occur in this chamber when air exits the pleural space with a cough or forceful expiration; the fluid will rise and fall in this chamber with pleural pressure changes associated with inspiration and expiration (tidaling).

A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?

Shortness of breath with crackles Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority. Feeling of warmth throughout the body occurs with the IV administration of dye for diagnostic procedures; it does not occur with IV fluids, such as 0.9% sodium chloride (NaCl) or D5W without an additive. Although infiltration at the catheter insertion site may occur, it is not the most serious complication; an altered respiratory status is the priority

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is what?

Sooty The mucous membranes of the respiratory tract may be charred after inhalation burns; this is evidenced by the production of sooty sputum. Frothy sputum usually is indicative of pulmonary edema. Yellow sputum usually is indicative of a respiratory infection. Tenacious sputum usually is indicative of respiratory infection.

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency during the first hours after surgery, what should the nurse do?

Suction as needed After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery. Although the application of an ice collar may limit edema or pain, it will not maintain patency of an airway that is compromised by secretions. A side-lying position will facilitate better drainage from the mouth. The client may not be reactive or have energy to cough or expectorate; the priority is to prevent secretions from entering the respiratory tract.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?

Tell me more about the conversation you had with your health care provider. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive. Instructing the client to ask the health care provider to clarify the procedure is not the priority; at this point, the nurse should collect more data. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance.

The nurse reviews common side effects of general anesthesia with a client scheduled for surgery. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience

a sore throat General anesthesia is delivered via an endotracheal tube that irritates the posterior pharynx and larynx. Side effects of general anesthesia do not include transient headaches or an elevated temperature. Hiccoughs, headaches, and an elevated temperature are systemic effects, not local effects, and are not side effects of general anesthesia

A client returning from a bronchoscopy is directed to not consume any food or drink any fluids for several hours. The nurse explains that these measures are taken to prevent what?

Aspiration To allow for the insertion of the bronchoscope, throat muscles are anesthetized, diminishing the protective gag reflex. Dysphasia is difficulty in talking and does not occur with a bronchoscopy. Projectile vomiting does not occur after a bronchoscopy. A general anesthetic usually is not used; therefore, paralytic ileus is not a complication.

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3-kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?

Cor pulmonale A sudden weight gain is an initial sign of right ventricular failure caused by COPD. Polycythemia is associated with polycythemia vera, not COPD. A sudden weight gain is not associated with compensated acidosis. Right, not left, ventricular failure occurs with COPD.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Elevate the head of the client's bed and obtain vital signs Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Auscultation of breath sounds should be done also. Discontinuing the IV access line is unsafe and may cause unnecessary discomfort if it must be restarted; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock; assessment for allergies should be done on admission. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is what?

Expected, but needs to be addressed Depression is an expected part of grieving that requires supportive care. Although depression is a normal response, intervention is necessary because it cannot be assumed that the depression will be of short duration. Depression is an expected response to the diagnosis of cancer; it does not indicate mental illness. Unless the client is suicidal, immediate acute care is not indicated.

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply.

Gag reflex Poor dentition Gum retraction The nurse should place a tongue blade along the side of the client's pharynx behind the tonsil and stimulate the gag reflex. Using a good light source, the nurse should inspect the interior of the mouth for poor dentition and gum retraction. These findings may indicate the presence of a respiratory disorder. Polyps may result from a long-term infection of the oral mucosa. The nurse should observe for the presence of polyps during an inspection of the nose. The presence of small, mobile nontender or shotty nodes is not a sign of the pathologic condition.

A client reports frequent awakening at night, insomnia, and excessive daytime sleepiness. The client adds that his bed partner also complains about his loud snoring. What does the nurse anticipate including in the patient's teaching plan?

Get fitted for an oral appliance that will bring the lower jaw and tongue forward Frequent awakening at night, insomnia, excessive daytime sleepiness, and loud snoring indicate obstructive sleep apnea. To help the client manage obstructive sleep apnea, the nurse may suggest that he get fitted for an oral appliance that will bring the mandible and tongue forward to enlarge the airway space. This will help prevent airway occlusion. A warm shower before bedtime may be suggested to a client who complains of sleeplessness resulting from anxiety or some other discomfort. The nurse should instruct the client to avoid taking sedatives and alcoholic drinks in the three to four hours before sleep.

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement?

I will maintain complete bed rest. Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.

Observe for chest wall trauma Assess breath sounds and respiratory effort The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort. Establishment of a patent airway by positioning occurs during the assessment of the airway and cervical spine. Level of consciousness is evaluated to determine mental status of the client. Clothing is removed to perform a complete physical assessment of the client.

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client. What should the plan include?

Preventing infection; the client is at risk for leukopenia The bone marrow is impaired with multiple myeloma; the effectiveness of white blood cells and immunoglobulin is reduced, which increases susceptibility to bacterial infections. Travel can be accomplished with careful planning and adequate rest periods. Although a positive mental attitude can contribute to quality of life and may even extend life, generally it does not change the prognosis. The client is encouraged to drink plenty of fluids to help dilute the Bence Jones protein fragments in the urine, which may help prevent kidney damage.

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing what?

Respiratory Acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), Hgb, and Hct are related to anemia.

A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination medication, Rifamate, composed of rifampin (Rifadin) and isoniazid (INH). The nurse evaluates that the teaching regarding the drug is effective when the client says what?

The most important thing I must do is Continue taking the medicine even after I feel better. The medication should be taken for the full course of therapy; most regimens last from six to nine months, depending on the state of the disease. Visual changes are not side effects of this medication. The medication should be taken one hour before meals or two hours after meals for better absorption. Urine or tears turning red-orange is a side effect of rifampin; while this should be reported, it is not an adverse side effect.

Which male patient should the nurse present information related to prostate cancer screening at an earlier age than that recommended for other patients?

African American African-American men tend to be diagnosed with prostate cancer at an earlier age, have more advanced disease at the time of diagnosis, and have a higher mortality rate than do white men; therefore, the nurse should focus information related to prostate cancer screening at an earlier age for the African-American patient than that recommended for other ethnicities.

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

Apply a precut dressing around the insertion site with the flaps pointing upward To prevent unraveling and potential aspiration into the airway, only a precut dressing should be used around the site. It should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula. The use of sterile cotton balls to cleanse the outer cannula is contraindicated; cotton balls have small threads that may be inhaled. The status of the cuff has no effect on tracheostomy care.

Which condition may cause respiratory alkalosis?

Asthma Asthma causes respiratory alkalosis. Atelectasis, poliomyelitis, and cystic fibrosis cause respiratory acidosis, not respiratory alkalosis

After multiple bee stings a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what?

Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply.

Checking the child's weight every day Calculating the dose of drug as carefully as possible Assessing the child regularly to help prevent electrolyte loss The child's weight should be checked and recorded daily to aid in the assessment of therapeutic and adverse effects. Pediatric doses should be calculated carefully to prevent an accidental overdose. Pediatric clients are at greater risk of electrolyte loss; therefore, they require closer and more cautious assessment to help prevent hypertension and stroke. Furosemide may cause stomach upset if it is taken on an empty stomach; the child should be given the drug with food to help prevent gastric upset. A child taking diuretics should not be exposed to sunlight for long periods because this action may precipitate fluid volume loss and heatstroke.

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. Which type of respirations does the nurse expect the client to exhibit?

Kussmaul's breathing Kussmaul's breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that usually is associated with pathology of the respiratory center in the brain.

What breathing exercises should the nurse review with a client experiencing emphysema?

Diaphragmatic exercises to improve contraction of the diaphragm With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration which are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.

A client with cardiac dysrhythmia is taking several medications. During a follow-up visit, the client reports fatigue to the primary health-care provider. Which medication does the nurse suspect the client is taking

Digoxin client with cardiac dysrhythmias who is taking digoxin may experience fatigue as a side effect. A client who is taking lidocaine should be closely monitored for heart rate and blood pressure changes as a means of preventing adverse effects. A client who is taking procainamide should be monitored for new dysrhythmias, dry mouth, blurred vision, bradycardia, hypotension, nausea, and anorexia. A client who is taking disopyramide should be monitored for altered blood pressure and apical pulse as a means of preventing adverse effects.

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?

Identify the absence of pulse. Once it is verified that the person is unresponsive and the emergency medical system has been activated, then whether the client is breathing should be established. Rescue breaths are not given with the hands-only basic life support method of CPR. Chest compressions are initiated as soon as it is identified that the person is not breathing; they are given at a rate of 100/min, to a depth of 2 inches each for 2 minutes, allowing full recoil between compressions. This quickly circulates the blood.

A nurse is assisting a health-care provider in providing palliative care to a client with lung cancer who has just undergone surgery. The provider instructs the nurse to assist the client with frequent position changes. Which complication is this intervention intended to prevent?

Ineffective airway clearance Clients who undergo lung surgery for the management of lung cancer may have ineffective airway clearance. This problem can be addressed with frequent position changes. Antipyretics and antiemetics should be administered to the client to treat fever and nausea, respectively. To manage fear related to treatment and prognosis, the nurse should monitor changes in the client's communication pattern and expression of feelings such as worthlessness or anxiety. The client should then be encouraged to identify the problem, redefine the situation, obtain needed information, generate alternatives, and focus on solutions.

A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's blood chloride level is decreased. What is the most efficient way this can be corrected?

Intravenous therapy Intravenous therapy ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.

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?

Notify the health care 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 is admitted to the emergency department with a stab wound of the left thorax. How should the nurse position the client?

On the left side with the head of the bed elevated When the client lies on the affected side, the unaffected lung can expand to its fullest potential; elevation of the head facilitates respirations by reducing the pressure of the abdominal organs on the diaphragm, allowing the diaphragm to descend with gravity on inspiration. Maximum lung expansion is inhibited when the head is not elevated. Although the high-Fowler position facilitates diaphragmatic movement, it is unclear as to what "left side supported" means. Pressure against the right thorax limits right intercostal expansion and gaseous exchange in the right lung. The abdominal organs restrict contraction of the diaphragm when lying flat in bed; also, lying flat in bed does not permit the diaphragm to drop by gravity as it does when in the high-Fowler position.

A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. How can the nurse help control the bleeding?

Pinching the nostrils together Pinching the nostrils together places pressure on the bleeding vessel, which can help control the bleeding. Tilting the head back will cause the blood to be swallowed, which can result in vomiting. Packing the bleeding nostril with tissue may cause further damage if done too firmly; some of the tissue may be left in the nose, causing an additional problem. Blowing the nose can prevent clotting, which can result in prolonged bleeding.

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?

Rises with inspiration and falls with expiration During inspiration, negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration, negative pressure in the pleural space decreases, causing fluid to drop in the chamber. If the system is closed to the atmosphere, as it should be, bubbles will not be present. If the system is closed to the atmosphere, as it should be, bubbles will not be present. Changes in intrapleural pressure cause fluid to rise on inspiration and fall on expiration (tidaling).

A client with tuberculosis is to begin a medication that combines isoniazid, rifampin, and pyrazinamide, and streptomycin sulfate therapy. The client says, "I've never had to take so much medication for an infection before." What should the nurse explain?

this type of organism is difficult to destroy Multiple drugs are administered because of the concern regarding drug resistance. Streptomycin sulfate is an antibiotic; it does not prevent the side effects of the combination medication. Multiple antitubercular drugs are necessary for an extended period, approximately six to eight months depending on the individual. Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.