Respiratory system level 2

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?

Absence of breath sounds over the affected area,

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify:

Altered mental status

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent?

An inaccurate interpretation

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)?

Aspirating gastric contents

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning.

Assess client's vital signs and lung sounds Administer oxygen via a ventilation bag Insert the catheter without applying suction Rotate the catheter while suction is applied

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time?

Assess the client's response to the interventions.

The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate breath sounds.

A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 70 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. What intervention should the nurse anticipate will be prescribed by the health care provider?

Breathing exercises

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 client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. The nurse should:

Discontinue or decrease the oxygen flow rate

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should:

Drain the fluid from the tubing

Surgery is performed on a client with a parotid tumor. The postoperative arterial blood gas values are pH 7.32, Pco2 53 mm Hg, and HCO3 25 mEq/L. What action should the nurse take?

Encourage the client to take deep, cleansing breaths

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of

Excessive swallowing

During the evening after a paracentesis, the nurse identifies that the client, although denying any discomfort, is very anxious. The best nursing approach is to:

Explore the client's concerns while administering the prescribed anxiolytic

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:

Having the client breathe into a paper bag

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube?

Hyperoxygenate with 100% oxygen before and after suctioning.

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?

Increase the oxygen flow rate per facility protocol.

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. The nurse's primary concern is to maintain:

Ventilatory exchange

What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia?

Loss of aerating surface

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?

Mechanical ventilation may be required next.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP)

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. The nurse should instruct the client that the purpose of pursed-lip breathing is to:

Promote elimination of CO2.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula

A nurse is providing education to a co-worker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which statement would be appropriate for the nurse to include?

Rapid removal of large amounts of pleural fluid may precipitate cardiovascular collapse.

A health care provider prescribes metaproterenol (Allupent) for a client who was recently admitted to the hospital. For what therapeutic effect should the nurse monitor the client?

Relaxed bronchial spasm

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 firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, a nurse identifies tachycardia, tachypnea, and dyspnea. What term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client?

Stridor

A client is experiencing severe respiratory distress. What response should the nurse expect the client to exhibit?

Tachycardia

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client?

The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula.

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?

Turning and positioning

The nurse is caring for a client with cancer of the lung who is considering the biological therapy (e.g., monoclonal antibodies, interferon) that has been recommended in the client's treatment plan. The nurse recalls that this therapy is:

Used as an adjuvant therapy with other therapies