Acute wk 2 Practice questions

Which of the following would be priority assessment data to gather from a client who has been dx with PNA? Select all that apply. A. Auscultation of breath sounds B. Auscultation of bowel sounds C. Presence of chest pain D. Presences of peripheral edema E. Color of nail beds

a, c, e

RESTRICTIVE RESPIRATORY DISORDERS

Pleural Effusion Pleurisy Atelectasis

Several teenagers and young adults are brought into the trauma unit with multiple injuries received in a gang fight. One victim of the fight sustains a chest injury that is diagnosed as pneumothorax. This injury is caused by an interruption to the normal intrapleural pressure, which is normally: higher than intrapulmonary pressure. a vacuum. positive. negative.

negative

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."

"The medicine will be prescribed for 10 days." Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

Reasons for inflating a cuff or balloon on an endotracheal or tracheostomy tube includes which of the following: 1. To prevent air leakage while on mechanical ventilation. 2. To exert traction on the trachea. 3. To prevent laryngeal edema. 4. To prevent aspiration of material into the lungs. 1 and 2 2 and 3 1 and 4 all the above.

1 and 4 correct answer is 1 and 4. the cuff on the tracheal tube is used to prevent air leakage while the client is being mechanically ventilated, and to prevent aspiration of material into the lungs for the endotracheal tube (although not all established trach tubes require this, that is how some clients can talk and eat and don't need the balloon inflated.) the cuff is never used to hold the tube in place, or to exert traction on the trachea (on the contrary, this must be watched carefully to be certain the cuff is not causing necrosis of tissue.) laryngeal edema would not be prevented by cuff pressure.

The cyanosis that accompanies bacterial PNA is primarily caused by which of the following? A. Decreased cardiac output B. Pleural effusion C. Inadequate peripheral circulation D. Decreased oxygenation of the blood

D. Decreased oxygenation of the blood

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse monitors which of the following lab values? A. Serum sodium B. Serum potassium C. Serum creatinine D. Serum calcium

c

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

Which of the following is the BEST definition of Acute Respiratory Failure? A failure of the lungs to maintain adequate oxygenation to meet the body's needs. An inability of the lungs to eliminate carbon dioxide at an adequate leve. A life- threatening, acute respiratory alteration which develops when a client with chronic lung problems no longer can meet ventilatory needs. A client who has an arterial oxygen tension of less than 55 mm Hg, with or without carbon dioxide retention.

A client who has an arterial oxygen tension of less than 55 mm Hg, with or without carbon dioxide retention.

A client has a chest tube. The nurse notices persistent bubbling in a water seal bottle attached to 25 cm of H20 suction when the chest tube is momentarily clamped close to the client. This indicates: A loose connection between the chest tube and pleurevac. A leak inside the client. A leak around the chest tube site. Insufficient suction.

A loose connection between the chest tube and pleurevac. Ordinarily this bubbling should stop when the tube is clamped close to the client.

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A temperature of 101.4°F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

A temperature of 101.4°F Heart rate of 120 beats/min A productive cough with yellow sputum A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

Chest Surgery

A thoracotomy, or the surgical opening into the thoracic cavity, is considered major surgery because the incision is large, cutting into bone, muscle, and cartilage. The two types of thoracic incisions are median sternotomy, performed by splitting the sternum, and lateral thoracotomy. Video-assisted thoracic surgery (VATS) is a minimally invasive thorascopic surgical procedure that in many cases can avoid the impact of a full thoracotomy.

Which of the following complications is associated with mechanical ventilation? A. GI hemorrhage B. Immunosuppression C. Increased cardiac output D. Pulmonary emboli

A. GI hemorrhage Stress ulcer basically.

Which of the following conditions can place a client at risk for acute respiratory distress syndrome? A. Septic shock B. COPD C. Asthma D. Heart failure

A. Septic shock You have to get some sort of high acute issue going on before you get to the point of ARDS.

Which intervention should the RN anticipate in a client who has been dx with ARDS? A. Tracheostomy B. Use of nasal cannula C. Mechanical ventilation D. Insertion of a chest tube

c

Atelectasis

Atelectasis is a condition of the lungs characterized by collapsed, airless alveoli. The most common cause of atelectasis is airway obstruction that results from retained exudates and secretions. This is frequently observed in the postoperative patient.

A client with acute asthma presenting with inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of meds right away? A. Beta-adrenergic blockers B. Bronchodilators C. Inhaled steroids D. Oral steroids

B. Bronchodilators "Inspiratory AND expiratory" is important to note. C and D are not right because this is emergent, those don't treat the immediate exacerbation.

Several teenagers and young adults are brought into the trauma unit with multiple injuries received in a gang fight.One of the clients requires a tracheostomy. It is possible to cut into the trachea easily because it is composed of: Cartilaginous rings Soft, bony tissue Lymphatic tissue Ciliated columnar epithelium

Cartilaginous rings

A 21-year-old client was accidently kicked in the chest during wrestling practice. In the Emergency Department (ED), he has asymmetrical chest movement with poor expansion of his left chest. Breath sounds are absent in the upper lobe. Chext X-ray reveals simple fractures of the fifth and sixth ribs.The most conclusive test to diagnose a collapsed lung is: Thoracentesis Arterial blood gases Chest X-ray Lung scan

Chest X-ray

A client is admitted to an ED with tachypnea, tachycardia, and hypertension. The client has been taking theophylline (Theo-Dur) for tx of asthma and erythromycin (Erythrocin) for an upper respiratory tract infection. Which conclusion by the nurse and action taken is correct? A. The client is experiencing an asthma attack and the RN requests an order for albuterol B. The client is experiencing septicemia and the RN requests and order for blood cultures C. The client is experiencing theophylline toxicity and the RN requests an order for a serum theophylline level D. The client is experiencing an allergic reaction to the erythromycin and the RN requests an order for diphenhydramine (Benadryl)

C. The client is experiencing theophylline toxicity and the RN requests Kind of a hard question, since it's a full-on pharm question. What do you think is going on with this pt in the stem? Asthma and some sort of bacterial infection (PNA). Indication this person is septic? Hypotension, tachycardia. This is a drug-interaction question (theophylline and erythromycin). Remember theophylline has a narrow TI, so you always gotta have that in the forefront of your mind. Erythromycin antibiotics have a LOT of interactions, so that's a specific one you would have to know. Would you see someone getting these 2 meds together in the real world? Probably not, too many interactions! We know A is wrong. Why not B? We are worried for sepsis (pt is experiencing hypotension and tachycardia), and the antibiotic in reality COULD be the wrong one, but still the TI is the most important thing to look at. Why not D? What characteristics in the stem alludes to characteristics of an allergic reaction? In allergic reactions you'd see rashes, skin issues and stuff. There's not really anything that pulls you towards allergic reaction. Erythromycin actually increases the availability of the theophylline Side note: Vancomycin has narrow TI as well and all kinds of side effects. Can cause fever! So don't think it's a wrong antibiotic because that's just a side effect of vanco. Dig a little deeper.

Which of the following clients demonstrates the typical clinical course & manifestations of acute respiratory distress syndrome (ARDS)? Client who is recovering from a bacterial infection, with clear breath sounds & normal ABG's. Suddenly his condition deteriorates rapidly. ABG's are found to be PaO2 85, pCO2 47, pH 7.2. After 6 LO2 administration, ABG's continue declining to PaO2 82, pCO2 50, pH 7.1. A client who is admitted with RR of 8, and ABG's of PaO2 85, pCO2 47, pH 7.3. After 6 LO2 administration, ABG's improve to PaO2 95, pCO2 35, pH 7.4. Client who is comatose and unresponsive. EEG reveals seizure activity. Clt has resp. rate of 24, with Cheyne- Stokes respirations. A client with RR of 36 and with diffuse crackles and rhonchi in lungs, substernal & intercostal retractions. Clt complains of heaviness in chest. ABG's are found to be PaO2 92, pCO2 37, pH 7.35.

Client who is recovering from a bacterial infection, with clear breath sounds & normal ABG's. Suddenly his condition deteriorates rapidly. ABG's are found to be PaO2 85, pCO2 47, pH 7.2. After 6 LO2 administration, ABG's continue declining to PaO2 82, pCO2 50, pH 7.1. the hallmark of ARDS is that the severely injured or ill client seems to improve, then gets much worse.

A 21-year-old client was accidently kicked in the chest during wrestling practice. In the Emergency Department (ED), he has asymmetrical chest movement with poor expansion of his left chest. Breath sounds are absent in the upper lobe. Chext X-ray reveals simple fractures of the fifth and sixth ribs.The most probable diagnosis would be: Bonchiectasis Closed pneumothorax Flail chest Pulmonary contusion

Closed pneumothorax

In taking a history from a client with a respiratory health deviation, specific questions should be asked to obtain information about: Color, amount & odor of sputum Presence of a positive Kernig's sign. Rebound tenderness on client's abdomen. Presence of muscular weakness or twitching.

Color, amount & odor of sputum

A client with PNA has a temperature ranging between 101F and 102F (38.3 and 38.8C) and periods of diaphoresis. Based on this info, which of the following nursing interventions would be a priority? A. Maintain complete bed rest B. Administer oxygen therapy C. Provide freq linen changes D. Provide fluid intake of 3L/day

D. Provide fluid intake of 3L/day Elevated temperature and sweatiness → fluid loss!

A client with a pneumothorax often complains of pain while breathing. Another clinical manifestation may include: Crackles and wheezes on the affected side Decreased respiratory rate Diminished or absent respiratory movement of the affected side. Bilateral decreased breath sound

Diminished or absent respiratory movement of the affected side. with a pneunothorax, the lung is not explanding and breath sounds would be diminished or absent on the affected side.

Immediate post-operative care of a thoracotomy client will include: Forcing po fluids to thin secretions. Effective respiratory hygiene measures. Notifying doctor immediately if there is any bloody drainage on chest dressing. Decreasing chest expansion to prevent strain on incision.

Effective respiratory hygiene measures. Respiratory hygiene begins immediately post-op, including turning and suctioning.

An Intensive Care Unit nurse has been informed that she will soon be admitting a client with Acute Respiratory Failure. The nurse would anticipate which of the following treatments will be done for this client? Promotion of hydration with IV fluids and encouragement of po fluids. Endotracheal intubation, mechanical ventilation and administration of drugs to paralyze client's respiratory efforts. Positioning in Trendelenburg position, to facilitate drainage of lung fluid. Nasogastric tube to continuous suction, to keep stomach decompressed.

Endotracheal intubation, mechanical ventilation and administration of drugs to paralyze client's respiratory efforts.

To treat a client's fungal pneumonia, the physician prescribed amphotericin B. Gradual dosage increase will follow the initial test dose of 1 mg in 250 ml of D5W infused over 2-4 hours. During amphotericin B therapy, the nurse needs to be aware that: A precipitate in the amphotericin B container indicates the proper drug concentration. Amphotericin B is compatible with normal saline solution, but not with any other solutions. Fever, chills, and nausea are common side effects from Amphotericin B, and usually can controlled by pre- medicating before administration. Other antibiotics can be piggybacked onto the I.V. line where amphotericin B is running.

Fever, chills, and nausea are common side effects from Amphotericin B, and usually can controlled by pre- medicating before administration. these are common but uncomfortable side effects for the client. Usually Benadryl & Acetominophen are given 30 minutes prior to administration of Amphotericin B, in order to control these side effects.

Flail Chest

Flail chest results from multiple rib fractures, causing an unstable chest wall. The diagnosis of flail chest is based on the fracture of two or more ribs, in two or more separate locations, causing an unstable segment. Initial therapy consists of airway management, adequate ventilation, supplemental O2 therapy, and pain control. The goal of therapy is to reexpand the lung and ensure adequate oxygenation.

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Humidify the oxygen as able. Administer cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

Increase fluid intake to 3 L/day if tolerated.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation

Increased vocal fremitus on palpation

Early symptoms of pneumonia include which of the following: Increased breath sounds over the effusion Increasing pain and shortness of breath Circumoral cyanosis and low 02 saturation Large amounts of thin, clear secretions.

Increasing pain and shortness of breath

A neonate was born at 32 weeks gestation, weight was 3 lbs. 2 oz. The baby displayed signs of sternal retractions, color was pale and muscle tone was flaccid. The baby should be watched closely for: Erythroblastosis Hypoglycemia Infant respiratory distress syndrome Gastrointestinal anomalies

Infant respiratory distress syndrome

The purpose of chest percussion is to: Strengthen respiratory muscles Stimulate deep breathing Increase circulation to the affected lobe. Loosen secretions

Loosen secretions

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Maintain adequate fluid intake. Maintain a 30-degree elevation. Splint the chest when coughing. Maintain a semi-Fowler's position. Instruct patient to cough at end of exhalation.

Maintain adequate fluid intake. Splint the chest when coughing. Instruct patient to cough at end of exhalation. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Obesity Pneumonia Malignancy Cigarette smoking Prolonged air travel

Obesity Malignancy Cigarette smoking Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

Appropriate nursing care for a client with an orally inserted endotracheal tube includes: Observing for skin impairment around the tube. Limiting oral hygiene, to prevent risk of aspiration. keeping the oxygen percentage high (at least 50%) to prevent atelectisis. Giving clear liquids in small amounts as tolerated.

Observing for skin impairment around the tube. this is very important. the skin around the tube can breakdown very quickly and must be assessed frequently and the position of the tube changed (for oral placement) from one side of the mouth to the other every other day or so.

pleurisy

Pleurisy, or pleuritis, is an inflammation of the pleura. The most common causes are pneumonia, TB, chest trauma, pulmonary infarctions, and neoplasms. Treatment of pleurisy is aimed at treating the underlying disease and providing pain relief.

Pulmonary Hypertension

Pulmonary hypertension can occur as a primary disease (idiopathic pulmonary arterial hypertension [IPAH]) or as a secondary complication of a respiratory, cardiac, autoimmune, hepatic, or connective tissue disorder (secondary pulmonary arterial hypertension [SPAH]). IPAH is a severe and progressive disease. It is characterized by mean pulmonary arterial pressure greater than 25 mm Hg at rest (normal 12 to 16 mm Hg) or greater than 30 mm Hg with exercise. IPAH is a diagnosis of exclusion. All other conditions must be ruled out. Although there is no cure for IPAH, treatment can relieve symptoms, increase quality of life, and prolong life. SPAH occurs when a primary disease causes a chronic increase in pulmonary artery pressures. SPAH can develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac shunts, chronic pulmonary thromboembolism, or systemic connective tissue disease.

Fractured Ribs

Rib fractures are the most common type of chest injury resulting from blunt trauma. Clinical manifestations include pain at the site, especially with inspiration and coughing. The main treatment goal is to decrease pain to promote effective breathing. Patients also need to be taught deep breathing, coughing, and use of incentive spirometry.

Auscultation is one means of assessing the respiratory system. Which of the following statements is true for respiratory auscultation? The bell of the stethoscope when listening to adults is used because it transmits higher pitched sounds. The examiner should ask the client to breathe rapidly and shallowly through his open mouth, in order to best hear lung sounds. The front and back of the thorax should be auscultated from top to bottom comparing one side to the other. The examiner should listen for one full minute at each location on the client's chest and back.

The front and back of the thorax should be auscultated from top to bottom comparing one side to the other.

Chest Tubes and Pleural Drainage

The purpose of chest tubes and pleural drainage is to remove the air, fluid, and/or blood from the pleural space and to restore normal intrapleural pressure so that the lungs can re-expand. Routine monitoring is done to assess adequate functioning of the chest tube unit. This involves observing for tidaling and bubbling in the water-seal chamber, assessing for subcutaneous emphysema, listening for breath sounds over the lung fields, and measuring the amount of fluid drainage.

Clients with chest tubes may restrict their breathing and movement to minimize pain and because they fear they may dislodge the tubes. The nurse can teach the client: Turning and coughing must be kept to a minimum to avoid dislodgement of the tubes. The tubes are taped and sutured securely and turning and coughing should be encouraged. That chest tubes seem far more frightening than other sorts of tubes. That the collection receptacle may make a bubbling noise if suction is used.

The tubes are taped and sutured securely and turning and coughing should be encouraged. Yes - It is important that the client know that the likelihood of dislodgement is low.

A 7 month old infant is playing in the playroom. When the infant's mother momentarily turns her back, the baby places a small toy in her mouth. She begins coughing, turns a dusky color, & is unable to make a sound. The mother screams for a nurse. When the nurse arrives in the playroom, which initial nursing action would be correct? Lay the infant supine on the floor, and perform 5 chest thrusts. Turn the infant prone with head down over the nurse's leg, & administer 5 back blows. Hold the infant on lap & do a finger sweep of the mouth to remove the toy. Do not touch the infant, but verbally encourage her to continue coughing.

Turn the infant prone with head down over the nurse's leg, & administer 5 back blows.

A client with bacterial PNA is to be started on IV antibiotics. Which of the following diagnostic tests must be collected before antibiotic therapy begins? A. Urinalysis B. Sputum culture C. Chest radiograph D. RBC count

b

Which of the following clients is/ are at risk of developing acute respiratory failure?1. A client who aspirated a piece of meat while eating.2. A victim of an earthquake with a crushing chest injury with flail chest3. A client who overdosed on barbiturates.4. A client with pulmonary edema from congestive heart failure. 1, 2 1, 2, 3 3, 4 1, 2, 3, 4

1, 2, 3 pulmonary edema from CHF is not typically a cause of acute respiratory failure, because it is insidious in onset. Respiratory failure usually happens from something relatively sudden in onset

Several teenagers and young adults are brought into the trauma unit with multiple injuries received in a gang fight. One of the clients requires a tracheostomy. When this client breathes through the tracheostomy tube, a common problem occurs because the nasal structure is bypassed for breathing. What is this common problem? The sense of smell is absent. Air is not warmed and humidified. Sense of taste is decreased. A loss of appetite occurs related to other loss of senses.

Air is not warmed and humidified.

Complications associated with lung scan can include which of the following? Allergic reactions to radio opaque day. Cardiac myopathy Myocardial perforation Bloody sputum

Allergic reactions to radio opaque day.

Oral Terbutaline (Brethaire) is prescribed for a client with bronchitis. Which comorbidity should prompt a nurse to monitor the client closely following administration of the medication? A. Strabismus B. Hypertension C. Diabetes insipidus D. Hypothyroidism

B. Hypertension This med will come up in a few weeks in class. Terbutaline has beta-1 and beta-2 action! So that's why it's not first-line drug. Diabetes Insipidus and SIADH are endocrine issues or due to some drugs related to this stuff. This person has bronchitis so we would think about bronchodilating being caused by this med. Side note: Strabismus → lazy eye. This is good to know when we get to peds; strabismus happens in children a lot? Side note 2: Terbutaline is also used to stop pre-term labor. MOA for that is because of the specialized beta receptor in the uterus also responds to this med. Side note 3: You can actually get hypertension from albuterol.

The RN interprets which of the following as an early sign of ARDS in a client at risk? A. Elevated carbon dioxide level B. Hypoxia not responsive to oxygen therapy C. Metabolic acidosis D. Severe, unexplained electrolyte imbalance

B. Hypoxia not responsive to oxygen therapy

Which of the following would be an appropriate expected outcomes for an elderly client recovering from bacterial PNA? A. A RR of 25-30 breaths/minutes B. The ability to perform ADLs without dyspnea C. A max loss of 5-10 pounds body weight D. Chest pain that is minimized by splinting the rib cage.

B. The ability to perform ADLs without dyspnea You want to see a return to functioning. Why would C throw someone off? It's an elderly person who's more fragile (often with HF, you might think PNA could be secondary to HF)...it's a trap though and trying to distract you. D is not a good outcome either.

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

A client with COPD is in the third post-op day following right sided thoracotomy. During the day shift, the client has required 10L O2 by mask to keep oxygen sat great than 88%. Based on this info, which action should be taken by the evening shift RN? A. Work to wean the o2 delivery down to 3L per mask B. Call RT for a nebulizer tx C. Check respiratory rate and notify the MD D. Administer a dose of ordered pain meds

C. Check respiratory rate and notify the MD Thoracotomy: incision to open up part of the lung lobe...like a chest tube? In COPD, if their lungs are very diseased, they remove lobe(s). First of all, is 88% ok? Ok for COPD. They still are taking 10 L though to keep them at 88%, so we actually do want to keep oxygen on for them, and not wean them off. Why not B? Nebulizers are not a good intervention for someone who needs 10L to keep them at 88%. What's a distractor? "Post-op". The fact that they need 10L is info that is important to pay attention to. This person is at risk for ARDS because they already have damaged alveoli and then we're pumping in 10L O2 just to keep them saturated. The more you pump up the oxygen, the more you might decrease their RR. This is not sustainable for COPD pt. You'd look at RR too when you give increasing oxygen to COPD pt. Trending is really very important.

An RN observes for early manifestations of ARDS in a client being treated for smoke inhalation. Which signs indicate the possible onset of ARDS in this client? A. Cough with blood-tinged sputum and respiratory alkalosis B. Decrease in both white and red blood cell counts C. Diaphoresis and low SaO2 unresponsive to increased o2 administration D. Hypertension and elevated PaO2

C. Diaphoresis and low SaO2 unresponsive to increased o2 What is the key word? Can you have diaphoresis for other reasons? Yes. Low SaO2? Yes. BUT, UNRESPONSIVE is the key here. They would be responsive to O2 administration normally, in someone without ARDS.

The mother of an 8 year old child being treated for right lower lobe PNA at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that the acetaminophen is not very effective. The nurse most appropriately tells the mother to: A. Increase the dose of the acetaminophen. B. Increase the freq of the acetaminophen C. Encourage the child to lie on the right side D. Encourage the child to lie on the left side

C. Encourage the child to lie on the right side You want to put your good lung UP, since it has normal lung function still so it can oxygenate. Bad side DOWN. The bad lung can't oxygenate well/enough so if you put it up and put the good lung down you're not going to get good enough oxygenation overall. In practice, you won't just leave them on that side only, you're going to be moving them around a lot ("respiratory toileting").

A Nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which of the following would the nurse expect to note in the client? A. Decreased RR B. Pallor C. Low arterial PaO2 D. Elevated arterial PaO2

C. Low arterial PaO2 What would be expected? B or C. Why not B? Think about which one is more specific to ARDS...pallor can also indicate other things, such as anemia.

While assessing a thoracotomy incisional area with a chest tube, the nurse feels a crackling sensation under the fingertips along entire incision. Which of the following should be the RN's first action? A. Lower HOB and call MD B. Prepare a tracheostomy tray C. Mark an area with a skin pencil at the outer periphery of the crackling D. Turn off the suction of the chest drainage system

C. Mark an area with a skin pencil at the outer periphery of the crackling Think: like cellulitis (you'd mark with skin pen as well). Air leakage in the way the chest tube is set up or how it was put it (usually how it's put in and how it's sealed). Usually has to do with the injury too and the nature of it. Air can escape into skin...it's like bubble-wrap when you touch the skin surface, and it sounds like rice crispies when you auscultate. Why not B? Does this person need a trach? No. It's just a distractor (we only ventilate when they can't breathe on their own). Why not D? That is not helpful. Side note: If you have a pt with a chest tube hooked up to suction, you can't unhook them off of suction unless you get a specific order from the MD for it (usually is at stage when they're trialing getting them off suction). You always connect it to suction and make sure it stays up-right and not knocked over at any point. If pt want to walk around, you can get a longer tube so they can walk within their room.

A client with PNA is experiencing pleuritic chest pain. Which of the following describes pleuritic chest pain? A. A mild but constant aching in the chest B. Severe midsternal pain C. Moderate pain that worsens on inspiration D. Muscle spasm pain that accompanies coughing

C. Moderate pain that worsens on inspiration Why C? Lining of the lungs are inflamed, and when you inflate the lungs during inspiration, that's when it will rub against the pleural cavity more. B is more with the heart. D is more with just the muscles.

Aminophylline (Theophylline) is administered to a client with acute bronchitis. A nurse administers the meds knowing that the primary action of this medication is to: A. Promote expectoration B. Suppress the cough C. Relax smooth muscles in the bronchial airway D. Prevent infection

C. Relax smooth muscles in the bronchial airway This drug you should know, most likely would end up on NCLEX. Problem with this drug is that it has a narrow therapeutic index.

A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes cardiac irregularities on the monitor. Which of the following is the most appropriate nursing intervention? A. Continue to suction B. Ensure that the suction is limited to 15 seconds C. Stop the procedure and re-oxygenate the client D. Notify the physician immediately

C. Stop the procedure and re-oxygenate the client Side note: speaking of suctioning...in lab prep, it had said to hyperoxygenate pt prior to suctioning, but in current practice, evidence actually don't recommend hyperoxygenating the pt before suctioning anymore because: if they have mucus or what not plugging up their airway, hyperoxygenating the pt beforehand won't actually do anything substantial. Probably still choose hyperoxygenate though if ever asked on exam.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site

Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

Cor Pulmonale

Cor pulmonale is enlargement of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is usually a preexisting condition in the individual with cor pulmonale. The most common cause of cor pulmonale is COPD. The primary management of cor pulmonale is directed at treating the underlying pulmonary problem that precipitated the heart problem.

Following extubation of an artificial airway, the client must be watched for respiratory distress. Signs of respiratory distress include: A sore throat Inspiratory stridor Hoarseness of voice Difficulty swallowing

Inspiratory stridor

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity

Less discomfort and faster return to normal activity The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

Pleural Effusion

Pleural effusion is a collection of fluid in the pleural space. It is not a disease but rather an indication of another disease. Pleural effusion is frequently classified as transudative or exudative according to whether the protein content of the effusion is low or high, respectively. § A transudative effusion occurs primarily in noninflammatory conditions and is an accumulation of protein-poor, cell-poor fluid. § An exudative effusion is an accumulation of fluid and cells in an area of inflammation. § An empyema is a pleural effusion that contains pus. The type of pleural effusion can be determined by a sample of pleural fluid obtained via thoracentesis (a procedure done to remove fluid from the pleural space). The main goal of management of pleural effusions is to treat the underlying cause.

Pneumothorax

Pneumothorax is air in the pleural space resulting in a partial or complete collapse of the lung. There are several types: -A spontaneous pneumothorax typically occurs due to the rupture of small blebs (air-filled blisters) located on the surface of the lung. These blebs can occur in healthy, young individuals or as a result of lung disease such as COPD, asthma, cystic fibrosis, and pneumonia. -Iatrogenic pneumothorax can occur due to laceration or puncture of the lung during medical procedures. -A tension pneumothorax occurs when there is a rapid accumulation of air in the pleural space, causing severely high intrapleural pressures with resultant tension on the heart and great vessels. Pneumothorax can occur from either nonpenetrating (closed) or penetrating (open) chest trauma Treatment depends on the severity of the pneumothorax and hemodynamic stability of the patient. Hemothorax is an accumulation of blood in the intrapleural space. Chylothorax is lymphatic fluid in the pleural space caused by a leak in the thoracic duct. Causes of both include trauma, surgical procedures, and malignancy.

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours

Positioning patient with "good lung" down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

After a sample of arterial blood is drawn for blood gas determination, which of the following actions is necessary? Preventing air from entering the syringe. Placing syringe in a warm water bath. Applying pressure to the puncture site for 15-20 minutes. Assuring that specimen is taken to the laboratory within an hour.

Preventing air from entering the syringe.

Refractory hypoxemia is the hallmark sign of a client with acute respiratory distress syndrome (ARDS). Which of the following best describes this concept of refractory hypoxemia ? Progressive arterial hypercarbia despite increasing the client's inspired 02 tension. Hypotension secondary to tissue hypoxia that is unresponsive to vasopressors. Progressive arterial hypoxemia despite increasing inspired 02 tensions. Hypoxemia which develops because of insufficient delivery of 02.

Progressive arterial hypoxemia despite increasing inspired 02 tensions. Arterial 02 levels drop, despite increasing amounts of 02 delivered, because of damage to the alveolar capillary bed, which prevents the extra O2 from being absorbed into the vascular space.

One of the complications following thoracic surgery is atelectasis. The most common cause is retained bronchial secretions. The nurse can best prevent this by the following intervention: Maintain patency of chest tubes. Suction every 8 hours. Promote effective deep breathing. Assess respiratory status frequently.

Promote effective deep breathing.

Pulmonary Edema

Pulmonary edema is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs. In severe circumstances, it may be considered a life-threatening medical emergency. The most common cause of pulmonary edema is left-sided heart failure.

Pulmonary Embolism

Pulmonary embolism is the blockage of pulmonary arteries by a thrombus, fat, or air emboli, or tumor tissue. Most pulmonary embolisms arise from thrombi in the deep veins of the legs. The most common risk factors for pulmonary embolism are immobility or reduced mobility, surgery within the last 3 months, history of deep vein thrombosis, and malignancy. Pulmonary infarction (death of lung tissue) and pulmonary hypertension are complications of pulmonary embolism. Pulmonary embolism may be diagnosed by spiral CT scan, V/Q scan, and/or pulmonary angiography. The objectives of treatment are to prevent further growth or extension of thrombi in the lower extremities, prevent embolization from the upper or lower extremities to the pulmonary vascular system, and provide cardiopulmonary support if indicated.

A 21-year-old client was accidently kicked in the chest during wrestling practice. In the Emergency Department (ED), he has asymmetrical chest movement with poor expansion of his left chest. Breath sounds are absent in the upper lobe. Chext X-ray reveals simple fractures of the fifth and sixth ribs.Immediately after the doctor removes a chest tube the nurse would maintain the site by: Suturing the site closed by pulling a purse string suture. Covering the site with moist saline gauze. Placing a dry 4x4 over the site. Sealing the site with vaseline gauze dressing.

Sealing the site with vaseline gauze dressing.

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Sudden onset of confusion Oral temperature of 102.3oF Coarse crackles in lung bases Clutching chest on inspiration

Sudden onset of confusion Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

Lung Transplantation

There are four types of transplant procedures available: single lung transplant, bilateral lung transplant, heart-lung transplant, and transplant of lobes from living related donor. Lung transplant recipients are at high risk for noninfectious and infectious complications. § Noninfectious complications: VTE, diaphragm dysfunction, and malignancy. § Infectious complications: bacterial, viral, fungal, and protozoal infections. Infections are the leading cause of death after transplant. Immunosuppressive therapy usually includes a three-drug regimen of cyclosporine or tacrolimus, mycophenolate mofetil (CellCept), and prednisone.

Which of the following clients is MOST at risk for developing Acute Respiratory Failure? Sasha, 7 months old, who had a bronchoscopy to remove an aspirated foreign object. George, 67 years old, a smoker, who is receiving IV antibiotics and nebulizer treatments for pneumonia. Tran, 22 years old, who is newly admitted comatose, from an overdose of barbiturates, and has a respiratory rate of 6. Bessie, 78 years old, with chronic emphysema & congestive heart failure, who has a respiratory rate of 40, and a pulse oximeter reading of 85%, on 2 L of oxygen.

Tran, 22 years old, who is newly admitted comatose, from an overdose of barbiturates, and has a respiratory rate of 6.