Chapter 19: Management of patients with chest and lower respiratory problems

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? Elevated troponin levels Elevated white blood count Elevated myoglobin levels Elevated B-type natriuretic peptide (BNP) levels

Elevated troponin levels

Which intervention does a nurse implement for clients with empyema? Institute droplet precautions Place suspected clients together Encourage breathing exercises Do not allow visitors with respiratory infections

Encourage breathing exercises

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote more efficient and controlled ventilation and to decrease the work of breathing Promote the client's ability to take in oxygen Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the strengthening of the client's diaphragm

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." "Hold the spirometer at your lips and breathe in and out like you normally would." "Take a deep breath and then blow short, forceful breaths into the spirometer." "When you're ready, blow hard into the spirometer for as long as you can."

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? Reddened area A blister 15-mm induration 5-mm induration

15-mm induration

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client who is receiving acetaminophen (Tylenol) for pain A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client who ambulates in the hallway every 4 hours A client with a nasogastric tube

A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for A kink in the ventilator tubing A cut or slice in the tubing from the ventilator Higher than normal endotracheal cuff pressure Malfunction of the alarm button

A kink in the ventilator tubing

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The client has a pneumothorax. The system has an air leak. The chest tube is obstructed.

The system has an air leak.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Absence of bloody drainage in the anterior/upper tube Skin around tube is pink. Bloody drainage is observed in the collection chamber. The tissues give a crackling sensation when palpated.

The tissues give a crackling sensation when palpated.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a malignant tumor. hyperthermia. a compromised skin graft. pneumonia.

a compromised skin graft.A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Tidaling Increased drainage Air leak Tension pneumothorax

air leak

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Syncope Dyspnea Ascites Hypertension

Dyspnea

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary.After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if a kink has developed in the tubing. See if the wall suction unit has malfunctioned. See if there are leaks in the system. See if the chest tube is clogged.

See if there are leaks in the system.

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? 0 to 4 mm 5 to 6 mm 9 mm 7 to 8 mm

0 to 4 mmThe Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

Arterial blood gas analysis would reveal which value related to acute respiratory failure? pH 7.28 PaCO2 32 mm Hg pH 7.35 PaO2 80 mm Hg

pH 7.28Explanation:Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? Troubleshoot to identify the malfunction. Notify the respiratory therapist. Reposition the endotracheal tube. Manually ventilate the client.

pg 559 Troubleshoot to identify the malfunction. Explanation: The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

2. "Inhale through your nose."4. "Slowly count to 3."3. "Exhale slowly through pursed lips."1. "Slowly count to 7."Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide. The nurse should instruct the client to first inhale through the nose to a slow count of 3. Next, the client should exhale slowly through pursed lips for a count of 7.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Impaired gas exchange related to ventilator setting adjustments Risk for infection related to endotracheal intubation and suctioning Risk for trauma related to endotracheal intubation and cuff pressure Impaired physical mobility related to being on a ventilator

564 Impaired gas exchange related to ventilator setting adjustments Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? A client exhibits symptoms of dyspnea. A client has a respiratory rate of 10 breaths per minute. A client requires permanent ventilation. A client has respiratory acidosis.

A client requires permanent ventilation.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? A nurse washes her hands before beginning client care. A highly virulent organism is present. Host defenses are impaired. Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses.

A nurse washes her hands before beginning client care.

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:1) Hold breath for about 3 seconds.2) Sit in an upright position.3) Place the mouthpiece of the spirometer in the mouth.4) Breathe air in through the mouth.5) Exhale air slowly through the mouth.

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin B6 Vitamin D Vitamin C Vitamin E

Vitamin B6

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? "Take a deep breath and then blow short, forceful breaths into the spirometer." "Hold the spirometer at your lips and breathe in and out like you normally would." "When you're ready, blow hard into the spirometer for as long as you can." "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Explanation: The client should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The client should then exhale slowly through the mouthpiece.

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? "The mucus-secreting glands are abnormal." "There are fibrous cysts in the lungs." "Allergic reactions cause inflammation in the lungs." "Early treatment can stop the progression of the disease."

"The mucus-secreting glands are abnormal." Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.(page 648)

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Influenza vaccine will prevent typical pneumonias." "Viruses like influenza are the most common cause of pneumonia." "Influenza is the major cause of death in the United States." "Getting the flu can complicate pneumonia."

"Viruses like influenza are the most common cause of pneumonia. Explanation: Influenza type A is a common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Hypoxia Oxygen-induced atelectasis Oxygen toxicity Oxygen-induced hypoventilation

(Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.)

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. vaccinations prescribed opioids hand antisepsis incentive spirometry

1. vaccinations2. hand antisepsisA powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A 92-year-old resident who needs extensive help with ADLs A resident who suffered a severe stroke several weeks ago A resident with mid-stage Alzheimer disease A resident with severe and deforming rheumatoid arthritis

A resident who suffered a severe stroke several weeks ago

Which action should the nurse take first when providing care for a client during an acute asthma attack? Administer prescribed short-acting bronchodilator. Send for STAT chest x-ray. Obtain arterial blood gases. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

Administer prescribed short-acting bronchodilator.

The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? How to splint the incision when coughing How to take prophylactic antibiotics correctly How to manage the need for fluid restriction How to milk the chest tubing

Ans: How to splint the incision when coughingFeedback:Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis

Aspiration pneumonia

A nurse should include what instruction for the client during postural drainage? Remain in each position for 30 to 45 minutes for best results. Lie supine to rest the lungs. Change positions frequently and cough up secretions. Sit upright to promote ventilation.

Change positions frequently and cough up secretions.

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? Direct lung damage Drug ingestion Chemical irritation Aspiration

Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrom

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Changes the setting on the ventilator to increase breaths to 14 per minute Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning

Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? Correct use of a ventilator Correct use of incentive spirometry Correct technique for rhythmic breathing Correct use of a mini-nebulizer

Correct use of incentive spirometry Explanation: Instruction in the use of incentive spirometry begins before surgery to familiarize the client with its correct use. You do not teach a client the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion? Resonance upon percussion Wheezing upon auscultation Mottled skin seen during inspection Decreased chest wall excursion upon palpation

Decreased chest wall excursion upon palpation Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound upon percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) Increases oxygen consumption Prevents aspiration Decreases hypoxemia

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. Inform the physician promptly that there is in imminent leak in the drainage system. Encourage the client to do deep breathing and coughing exercises. Document that the chest drainage system is operating as it is intended.

Document that the chest drainage system is operating as it is intended. Explanation: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Hemoptysis and dysuria Dyspnea and wheezing Sore throat and abdominal pain Nonproductive cough and normal temperature

Dyspnea and wheezing In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.(page 577)

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake. Offer nutritious snacks 2 times a day.

Encourage increased fluid intake.

The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increase in women smokers Increased incidence among the elderly Few early symptoms Increased exposure to industrial pollutants

Few early symptoms Explanation: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypotension, hyperoxemia, and hypercapnia Hypercapnia, hypoventilation, and hypoxemia Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders, ACUTE RESPIRATORY FAILURE, p. 556. Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders - Page 556

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority? Ineffective airway clearance Infection risk Acute pain Impaired gas exchange

Ineffective airway clearance Explanation: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis of acute pain is probable, gas exchange is a higher priority. Ineffective airway clearance is not the greatest concern because the problem is with ventilation. Infection risk is present but is not the highest-priority client need.

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? "It is fine if I eat sushi with a little bit of soy sauce." "It is all right if I drink a glass of red wine with my dinner." "It is all right if I have a grilled cheese sandwich with American cheese." "I am going to have a tuna fish sandwich for lunch."

It is all right if I have a grilled cheese sandwich with American cheese." Explanation: Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? It increases the respiratory rate to improve oxygenation. It will prevent the alveoli from overexpanding. It will assist with widening the airway. It prolongs exhalation.

It prolongs exhalation.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Oxygen analyzer Water-seal chest drainage set-up Manual resuscitation bag

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders, Chart 19-15 Initial Ventilator Settings, p. 563. Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders - Page 563

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? Percuss the client's lungs and thorax. Have the client perform incentive spirometry. Measure the client's oxygen saturation. Determine whether the client can now perform forced expiratory technique (FET).

Measure the client's oxygen saturation Explanation: The client's response to suctioning is usually determined by performing chest auscultation and by measuring the client's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? Inflate the cuff to the highest possible pressure in order to prevent aspiration. Keep the tracheostomy tube plugged at all times. Monitor the pressure in the cuff at least every 8 hours Deflate the cuff overnight to prevent tracheal tissue trauma.

Monitor the pressure in the cuff at least every 8 hours Explanation: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the client from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? Secure the chest tube with tape. Place the end of the chest tube in a container of sterile saline. Apply an occlusive dressing and notify the physician. Clamp the chest tube immediately.

Place the end of the chest tube in a container of sterile saline.

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Using incentive spirometry Using prescribed opioids Mobilizing early Receiving vaccinations

Receiving vaccinations

The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client? Signs and symptoms of pulmonary infection Residual effects of compromised oxygenation Swallowing ability and signs of aspiration Activity level and role performance

Residual effects of compromised oxygenation

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? Fever Weight loss Shortness of breath Headache

SOB Explanation:Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if the wall suction unit has malfunctioned. See if there are leaks in the system. See if a kink has developed in the tubing. See if the chest tube is clogged.

See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders, CHEST TRAUMA, Pneumothorax, p. 596.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Stabbing pain during respiratory movement Dullness or flatness on percussion over areas of collected fluid Fever and chills Dyspnea and coughing

Stabbing pain during respiratory movement Explanation: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator. Check for an apical pulse. Suction the client's artificial airway.

Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Sudden onset of lung impairment in a client who had normal lung function Sudden onset of lung impairment in a client who had compromised lung function Insidious onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function

Sudden onset of lung impairment in a client who had normal lung function

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Hold each position for 5 minutes. Lay in bed with the head on a pillow. Perform drainage 1 hour after meals. Take prescribed albuterol (Ventolin) before performing postural drainage.

Take prescribed albuterol (Ventolin) before performing postural drainage. Explanation: When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

A mediastinal shift occurs in which type of chest disorder? Tension pneumothorax Cardiac tamponade Simple pneumothorax Traumatic pneumothorax

Tension pneumothorax Explanation: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Runs of ventricular tachycardia Blood pressure remains stable Respiratory rate of 16 breaths/minute Oxygen saturation of 93%

Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? Direct lung damage Drug ingestion Chemical irritation Aspiration

chemical irriation

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: milk the chest tube every 2 hours. report fluctuations in the water-seal chamber. encourage coughing and deep breathing. clamp the chest tube once every shift.

encourage coughing and deep breathing.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Use of a cooling blanket Endotracheal suctioning Encouragement of coughing Incentive spirometry

endo suction

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? Pulmonary contusion Simple pneumothorax Cardiac tamponade Flail chest

flail chestWhen a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.p. 627

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.46, PaO2 80 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

pH 7.28, PaO2 50 mm HgARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? "The tube will provide a route for medication instillation to the lung." "The tube will drain secretions from the lung." "The tube will drain air from the space around the lung." "The tube will allow air to be restored to the lung."

pg 593 The tube will drain air from the space around the lung." Explanation: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: area of redness is measured in 3 days and determines whether tuberculosis is present. presence of a wheal at the injection site in 2 days indicates active tuberculosis. skin test doesn't differentiate between active and dormant tuberculosis infection. test stimulates a reddened response in some clients and requires a second test in 3 months.

skin test doesn't differentiate between active and dormant tuberculosis infection.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: pressure support ventilation (PSV). synchronized intermittent mandatory ventilation (SIMV). assist-control (AC) ventilation. continuous positive airway pressure (CPAP).

synchronized intermittent mandatory ventilation (SIMV).

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? Use a heat or cold application. Use a prescribed analgesic. Avoid using a pillow while splinting. Turn onto the affected side.

turn onto the affected side

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Pressure cycled Time cycled Negative pressure Volume cycled

volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders, Mechanical Ventilation, pp. 559-560.