Ch 53
The nurse is caring for a patient who has just been admitted with atelectasis and anticipates which possible treatments for this patient? (Select all that apply.)
-Chest tube -Surgical removal of the affected lung -Assisted ventilation
A nursing instructor is discussing ways that the respiratory tract protects itself from bacteria and shares with the students that it is done in which ways? (Select all that apply.)
-Cough and sneeze reflex -Goblet cells -Nasal cilia
The nurse is admitting a patient with an obstructive respiratory disorder. The nurse knows this includes which disorders? (Select all that apply.)
-Cystic fibrosis -Asthma
The nurse is caring for a patient with pneumonia. The nurse would expect to see which symptoms? (Select all that apply.)
-Difficulty breathing -Fever -Oxygen saturation of 88%
The nurse is teaching a class about common upper respiratory infections to parents of preschoolers. The parents correctly respond that which are examples of upper respiratory infections? (Select all that apply.)
-Pharyngitis -Sinusitis -Laryngitis
The nurse is aware that patients with bronchiectasis often have an underlying medical condition that increases the chance for infection. What are some of these medical conditions? (Select all that apply.)
-Rheumatoid arthritis -AIDS -Organ transplant patient
A student asks the pharmacy instructor where air exchange takes place in the human body. What would be the instructor's best response?
Air exchange in the human body takes place in the alveoli.
The nurse is caring for a 6-year-old patient with cystic fibrosis. The parents ask how the cystic fibrosis started. The nurse explains that the key feature in the presentation of cystic fibrosis includes what?
Airway obstruction
A nurse in the postanesthesia care unit is caring for a 77-year-old male patient after hip replacement surgery. While assessing the patient, the nurse notes crackles, dyspnea, cough, and changes in movement of the chest wall. The nurse would suspect the patient has developed what?
Atelectasis
A nurse is caring for a 73-year-old woman who just arrived on the medical surgical floor following a radical mastectomy for breast cancer. The nurse will encourage the patient to cough and breathe deeply to help prevent what?
Atelectasis
The nursing instructor is discussing cystic fibrosis (CF) with his clinical group. What would the instructor cite as the hallmark pathology of CF?
Bronchial mucous plugging, inflammation, and tissue damage
A patient presents to the clinic with a temperature of 101.5°F; malaise, myalgia, arthralgia, and a purulent, productive cough. The patient states The fever just started today but I have had this cough for many, many months. What would the nurse suspect the patient has?
Bronchiectasis
The nurse is developing the teaching portion of a care plan for a patient with asthma. What would be an important component for the nurse to emphasize?
Chronic inhalation of nonallergic inhaled irritants can trigger an attack.
While assessing a new patient on the unit, the nurse notes the following: productive cough, respiratory rate of 22, oxygen saturation of 90%, and increased secretions. The patient has a 20-year history of smoking 1.5 packs of cigarettes daily. What chronic condition might this patient have?
Chronic obstructive pulmonary disease (COPD)
A patient arrives in the emergency room with an attack of acute bronchiectasis. The nurse knows that the principal pathologic finding in the diagnosis of bronchiectasis includes what?
Chronic, irreversible dilation of the bronchi and bronchioles
A nurse is discussing ways the body protects itself against infection. What are the microscopic, hair- like projections of the cell membrane found in the nasal cavity, which transport foreign substances toward the throat where it can be swallowed and kept away from the respiratory system?
Cilia
While discussing gas exchange, the instructor would tell the students that oxygen and carbon dioxide enter and leave the body by what method?
Diffusion
A nurse is discussing cystic fibrosis (CF) with a couple who have just given birth to an infant with this disorder. The nurse explains that the respiratory component of this disease is caused by what?
Excessive respiratory tract secretions
A patient is admitted with an asthma attack caused by an allergic reaction to a medication. The nurse is aware that this severe allergic response is triggered by the immediate release of what?
Histamine
The nursing instructor is discussing acute respiratory distress syndrome (ARDS) with her clinical group. What signs and symptoms would the instructor present to the students as characteristic of ARDS?
Hypoxia
A nurse is caring for an 80-year-old patient with pneumonia. The most appropriate nursing diagnosis for this patient would be what?
Impaired gas exchange
The anatomy and physiology teacher is discussing ventilation with the nursing students. What would the instructor say causes an increased respiratory rate?
Increased stimulation of the respiratory center
A patient is complaining of an inability to breathe nasally because of severe rhinitis. The nurse is aware that the nose plays what important role in breathing that is disrupted when the nasal passages are blocked?
Inspired air is warmed and humidified
A 39-year-old teacher with bronchitis has been up all night with intense coughing spasms and asks the nurse How is all this coughing related to my bronchitis? The nurse tells the patient that a cough is initiated by what?
Irritation
The nurse is caring for a patient who suffered a head injury and is now having difficulty breathing. The nurse knows that this patient may have injured what part of the central nervous system?
Medulla oblongata
The nursing instructor is discussing the oxygenation process and explains unoxygenated blood is received from the right ventricle by the alveoli. The delivery of this blood is referred to as what?
Perfusion
A nurse is caring for a 45-year-old patient with acute respiratory distress syndrome (ARDS). The nurse is aware that this disease is characterized by what?
Progressive loss of lung compliance and increasing hypoxia
A nurse is caring for a patient with chronic bronchiectasis. The nurse should assess the patient for what clinical manifestations?
Purulent cough
A patient returns to the unit after thoracic surgery with a water-sealed chest drainage system. What should the nurse instruct the patient and the family that this drainage system is used for?
Re-expanding the lung and restoring the negative pressure to the space between the pleura
The nursing instructor is teaching a class on respiratory disorders and asks the students What condition is a result of the upper airways response to pollen, mold, or dust?
Seasonal rhinitis
A woman has just given birth to a premature infant. The mother asks why the infant is having such a hard time breathing. The nurse explains that the infant's alveoli are unable to stay open. What is the infant lacking that is necessary for correct functioning of the alveoli?
Surfactant
The nursing instructor is discussing the need for lubrication of the alveoli for effective gas exchange and is produced by type II cells of the alveoli. The students know that what substance is produced by type II cells of the alveoli?
Surfactant
A patient asks the nurse what causes a cold. The nurse would tell the patient that the common cold is most often caused by which type of microorganism?
Virus
The nurse in the clinic is caring for a patient who has seasonal rhinitis and the patient wants to know what causes this to occur. What is the nurse's best response?
Your upper airways are experiencing an inflammatory response to an inhaled antigen that is causing you to have sneezing and watery eyes.
The clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what they could have done to minimize the risk of contracting this disease. What would be the nurse's best answer?
The most important risk factor for COPD is cigarette smoking.
The pediatric nurse practitioner is caring for a child who is diagnosed with cystic fibrosis (CF). The parents ask what the treatment is for because CF is considered a terminal illness. What would be the nurse's best response?
Treatment is aimed at maintaining airway patency as much as possible.