Unit 4 EAQ

a 40 year old architect with a malginaant parotid tumor is treated aggressively with radiation therapy and surgery. postsurgical laboratory results indicater ABG values are pH 7.32, PCO2 53, HCO3 25. which action should be taken by the nurse?

Asking the client to cough productively and take deep breaths

When a client returns from a bronchoscopy the nurse wthholds food and fluid for several hours to prevent what?

Aspiration

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?

Barrel Chest

A healthcare provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning?

Gurgling sounds with each breath

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, and restlessness.

A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response?

I may have a sore throat

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, how is mild exercise expected to affect respirations?

Increase to 24 breaths per minute

The nurse is providing postoperative care for an obese adult who had major abdominal surgery. The client has a history of smoking three packs of cigarettes daily. Which lab/diagnostic finding will the nurse check for the most accurate measurement of the client's respiratory status?

Oxygen Saturation

A client who had a total laryngectomy is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" Which is the best response by the nurse?

"Perhaps I can have someone from the Laryngectomy Club come speak with you."

the nurse performs preoperative teaching related to a subtoatal thyroidectomy. the nurse evaluates that the client understands the teaching about the local effects of the administration of a general anesthetic when the client states, immediately after surgery i may experience?

Discomfort swallowing

After abdominal surgery a client should be encouraged to turn from side to side and to engage in deep breathing exercises. The nurse explains that these activities are essential to prevent which condition?

Respiratory Acidosis

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what likely cause of the spontaneous pneumothorax?

Rupture of a subpleural bleb

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?

Decreased filling of the right side of the heart

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs?

Diminished breath sounds on the affected side

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

Diminished breathe sounds

After a gastroscopy the nurse assesses the client for the return of the gag reflex by?

Touching the pharynx with a tongue depressor

An 84 year old client with a history of hemoptysis and cough for the last 6 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. the nurse's priority is to?

notify the practitioner of the observation