Respiratory System

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

The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. Which main purpose of the third chamber of the underwater drainage system should the nurse consider when planning care?

Controls the amount of suction

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client?

Encourage range of motion to the client's arm on the affected side

Three weeks after having a laryngectomy a client asks about what to do if the laryngectomy tube becomes dislodged. An appropriate nursing response is to instruct the client to take which action?

Reinsert another tube as soon as possible

The nurse is performing a physical assessment of a newly admitted client. Identify the area of the chest on the illustration that produces resonance when percussed

b

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply.

Headache Irritability Restlessness

A client who was discharged from the hospital after a rhinoplasty for a fractured nose complains of nasal bleeding. Which activity of the client might have led to this condition?

Performing Valsalva maneuvers

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD?

Cardiac problems

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply.

Confusion Hypocapnia Tachycardia

Which data regarding chest palpation findings is accurate?

Data 3

The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds?

Diminished breath sounds

The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? Select all that apply.

"Have you ever smoked elicit street drugs?" "What equipment helps you manage your respiratory problems?"

The nurse auscultates fine crackles in a client who has arrived in the emergency department with 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.

A nurse is teaching a community health class about the risk factors for cancer. Which factor has the least influence in predisposing an individual to cancer of the larynx?

Inadequate dental hygiene

Which chest examination findings can be observed in a client with pneumonia?

Increased fremitus over affected area on palpation

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff?

Inflate the cuff before the feeding and for 30 minutes after each feeding

Which action performed by the nursing student during the chest examination of a client needs correction?

Placing the stethoscope over bony prominences

A client with obstructive airway disease reports to the nurse about experiencing spasms of coughing. What suggestion should the nurse provide to help the client successfully manage this problem?

Postpone the planned vacation to go skiing.

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply.

Oxygenation Drowsiness Mental confusion

A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during swallowing. Which statement of the client indicates the need for further teaching?

"I should drink more water and other thin liquids."

The nurse is interpreting responses to tuberculin skin testing in a 58-year-old client with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction?

An 11-mm area of induration at the test's injection site

A nurse is suctioning a client's airway. Which nursing action will limit hypoxia?

Apply suction only after catheter is inserted

A client is admitted to the hospital with chronic asthma. Which complication should the nurse monitor in this client?

Atelectasis

The nurse is caring for different clients in a healthcare setting who are diagnosed with respiratory disorders. Which client may have the anteroposterior chest diameter equal to the lateral chest and the slope of the ribs more horizontal to the spine?

Client 1

A client has a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness in the postanesthesia care unit?

Encouraging deep breathing

After a laryngectomy is scheduled, what is the most important factor for the nurse to include in the preoperative teaching plan?

Establishing a means for communicating postoperatively

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do first?

Inspect the catheter

What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy?

Keep the stoma covered with a scarf.

The nurse is caring for a client who has a tracheostomy tube with a high-volume, low-pressure cuff. What does the cuff prevent?

Mucosal necrosis

A client is experiencing dyspnea. In which position should the nurse place the client?

Orthopneic

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication?

Subcutaneous emphysema on the second postoperative day

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

Class III

The nurse reviews teaching with a client who has laryngeal cancer and is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client makes which statement about what he will be able to do after recovering from surgery?

After surgery, I will still be able to chew and swallow food.

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action?

Apply a wound dressing.

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client?

Mediastinal shift

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first?

Administer oxygen as prescribed.

A client is diagnosed with cancer of the larynx and is scheduled for a total laryngectomy. What should the nurse initially include in the preoperative teaching plan?

Allow the client an opportunity to ask questions

To prevent potential aspiration, what technique should a nurse use when cleaning a tracheostomy tube that has a non-disposable inner cannula?

Apply precutdressing around the insertion site with the flaps pointing upward.

A nurse is involved in an international committee to address global health problems. What suggestion is most appropriate for the nurse to make to best meet the challenge associated with a potential emerging influenza pandemic?

Establish a global surveillance plan.

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube?

Has a low-pressure cuff

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue?

Schedule nursing activities to allow for rest

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nursemake it a priority to use? Select all that apply.

Surgical mask Gown Gloves

A nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which statement made by the client indicates the need for further teaching?

"I will shake the whole unit vigorously one or two times."

A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis?

Client C