Chapter 38: Prep U
The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse?
"After I dry your face, I can apply powder to absorb the moisture and protect your skin."
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
"I can assist you to the bathroom and back to bed."; The client can move in bed, and ambulate while carrying the drainage system as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted, to make sure it stays intact and to monitor for safety
Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?
7.5; number of packs smoked per day by number of years smoked
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?
8 L/min oxygen via nasal cannula; The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.
A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:
A: "The air is thicker or more viscous with humidity, thus it is harder for you to breathe." People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?
A: An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.
Q: Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
A: Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
Q: A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
A: Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients Extraneous: - Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. - Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. a. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. - Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia?
A: Pursed-lip breathing and diaphragmatic breathing - Pursed-lip breathing and diaphragmatic breathing are helpful for clients who have excessive levels of carbon dioxide in the blood. Deep breathing, incentive spirometry, and use of nasal strips does not eliminate as much carbon dioxide from the blood.
Q: The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
A: Residual Volume (RV) During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.
The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?
A: Respiratory rate and depth - The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiological damage from respiratory depression, or loss of consciousness. - The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:
A: atelectasis Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:
A: bronchospasm When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous (accumulation of excessive fluid), mucus production increases, and inflammatory chemical mediators cause bronchospasm.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
A: congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
Q: A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
A: croup Croup and epiglottitis are common in young children. - The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. - Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. - The symptoms include nonproductive cough, dyspnea, and wheezing.
Q: A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
A: educating the client on the use of incentive spirometry - Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. - Pursed-lip breathing primarily addresses dyspnea and anxiety. - Suctioning is only indicated when clients are unable to independently mobilize secretions. - Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
Q: A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
A: flow meter The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. Extraneous: - An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. - An adhesive nasal strip increases the nasal diameter and promotes easier breathing. - A nasal cannula is a hollow tube used for delivering a small concentration of oxygen.
Q: A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
A: pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion).
What is the action of codeine when used to treat a cough?
A: suppresant Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas; Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?
Bronchitis; Bronchitis refers to a condition in which the airways become inflammed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.
When the emergency room nurse assesses the pulse oximeter on a client and it reveals 105%, the nurse determines that the most likely explanation for the value is:
Carbon monoxide poisoning results in false high readings; edema at the sensor site produces false low readings.
A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client?
Cough medicine with an antihistamine; - The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. - The client with diabetes should avoid cough medicine with a high sugar content. - The client with thyroid disorders should avoid cough medicine containing iodine. - The client with hypertension should avoid cough medicine with decongestants.
The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?
Crackles in the lower lobes; People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.
The nursing assessment reveals reduced fremitus. This manifestation is consistent with which conditions? Select all that apply.
Fremitus refers to the vibration of air movement through the chest wall. It is best felt by placing the balls of the palms of your hand on the client's back as the client says "99." The intrascapular space is a good area to feel tactile fremitus because it diminishes as you move out in the lung fields. Decreased fremitus may occur with pleural effusion, pulmonary edema, emphysema, or bronchial obstruction. Left-sided heart failure will result in pulmonary edema, causing decreased fremitus.
What assessments would a nurse make when auscultating the lungs?
If cardiovascular function is not adequate, the results will lead to impaired oxygenation; therefore, it is important to assess cardiovascular function when assessing respiratory function. Both systems work in conjunction with each other, and the proximity of lung auscultation lends itself to assessment of cardiovascular function. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.
A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient?
Inhalers differ in the amount of dexterity that is required in order to deliver an accurate dose, but each requires some degree of coordinated activity and the ability to follow directions on the part of the patient. For a patient with decreased cognition, a nebulizer may be more appropriate on account of the fact that the patient passively inhales the entire dose
You are caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which of the following items should you place in the patient's room to respond appropriately to accidental disconnection of the chest tube from the drainage device?
Keep bottle of sterial saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water.
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
Nasal cannula Simple oxygen mask Partial rebreather mask; Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.
The nurse should assess for respiratory depression before and after the administration of which drugs?
Opioid analgesics; Opioids depress the medullary respiratory center, resulting in decreased respiratory rate. Antibiotics, antivirals, diuretics, and proton-pump inhibitors do not have this effect.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
Pleural effusion; Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
The nurse is caring for a 70-year-old client with COPD. Which vaccine will the nurse offer the client?
Prevnar 13 ®; All clients over 65 years old or anyone with a compromising chronic health condition should be offered Prevnar 13 ®. This vaccine is effective in reducing 13 strains of streptococcal pnuemoniae. The other choices are not appropriate for this client.
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
Rapid respirations; Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted?
The newly hired nurse auscultates breath sounds as the client breathes through the nose; Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True; This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
Vesicular; Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. - Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. - Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.
A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?
When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150mm/hg.
The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
face tent; aface tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. This device is most appropriate for a client with facial burns.
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position; Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
pneumonia; Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?
pursed-lip breathing; Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia
