Chapter 21 prep U med surg

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

"The mucus-secreting glands are abnormal."

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration?

20 to 25 mm Hg

Which is a correct endotracheal tube cuff pressure?

22 mm Hg

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

5 to 20 minutes.

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

A partial rebreathing mask

A client with chronic lung disease is prescribed chest percussion. For which reason will the nurse question this treatment for the client?

Age 75 years

Constant bubbling in the water seal of a chest drainage system indicates which problem?

Air leak

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides.

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Aspiration pneumonia

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds

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?

Chemical irritation

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

Chest tube drainage, 190 mL/hr

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia

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

Continues assessing the client's respiratory status frequently

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP)

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?

Deviation from the midline

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

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?

Endotracheal suctioning

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?

Every 2 to 4 hours

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

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?

Manual resuscitation bag

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?

Nonrebreather mask

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Nonrebreathing mask

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?

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

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?

Runs of ventricular tachycardia

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:

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.

A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply.

Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway.

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

Swimming

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume cycled

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume-controlled

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping his airway patent

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

"Before you do the exercise, I'll give you pain medication if you need it."

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.

"I just finished eating my lunch, I'm ready for my CPT now."

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting?

0.5

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg

What dietary recommendations should a nurse provide a client with a lung abscess?

A diet rich in protein

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

Assess pulse and blood pressure.

What assessment method would the nurse use to determine the areas of the lungs that need draining?

Auscultation

nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels

The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated?

Blood pressure increase of 20 mm Hg from baseline

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

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?

Hyperbaric

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

Orthopnea

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?

Oxygen toxicity

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.

PaO2 of 64 mm Hg Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

A client with a chronic lung disease is prescribed postural drainage. Place in order the nurse's actions to perform this procedure. Use all options.

Plan to do the procedure before a meal. Provide medication to loosen secretions before the procedure. Obtain an emesis basin, sputum cup, and paper tissues. Instruct client to breathe in through the nose and out through pursed lips. Place client in position to drain the lower lobes for 10 to 15 minutes and then cough. Place client in position to drain the middle lobe for 10 to 15 minutes and then cough. Place client in position to drain the upper lobes for 10 to 15 minutes and then cough.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Routinely deflating the cuff

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Take prescribed albuterol (Ventolin) before performing postural drainage.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

The patient will have an insertion of a tracheostomy tube.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium

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.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

Venturi mask

The nurse is performing chest auscultation for a patient with asthma. How does the nurse describe the high-pitched, sibilant, musical sounds that are heard?

Wheezes

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 compromised skin graft.

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

amoxicillin-clavulanic acid.

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include

hoarseness.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?

no longer than 10 seconds

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:

synchronized intermittent mandatory ventilation (SIMV).