chp 19

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 Contacts the respiratory therapy department to report the ventilator is malfunctioning Continues assessing the client's respiratory status frequently

Continues assessing the client's respiratory status frequently 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 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 Use of a cooling blanket Encouragement of coughing Incentive spirometry

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

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? Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

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. Request order for patient-controlled analgesia pump Monitor and record hourly intake and output. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Monitor pulmonary status as directed and needed.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? Positive Negative Uncertain Borderline

Negative The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

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? pH PCO2 PaO2 HCO3

PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1"Slowly count to 3." 2"Inhale through your nose." 3"Slowly count to 7." 4"Exhale slowly through pursed lips."

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." "You must consume a diet rich in protein, such as chicken, fish, and beans." "You must consume a diet low in fat by limiting dairy products and concentrated sweets." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta."

"You must consume a diet rich in protein, such as chicken, fish, and beans." The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

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? 45 mm Hg 84 mm Hg 58 mm Hg 120 mm Hg

84 mm Hg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient? A Venturi mask An oropharyngeal catheter A nonrebreathing mask A nasal cannula

A Venturi mask The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen way that allows a constant flow of room air blended with a fixed flow of oxygen. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive.

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 has respiratory acidosis. A client requires permanent ventilation.

A client requires permanent ventilation. A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed client. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

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

A nurse washes her hands before beginning client care. HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

On auscultation, which finding suggests a right pneumothorax? Bilateral inspiratory and expiratory crackles Bilateral pleural friction rub Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax

Absence of breath sounds in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Respiratory acidosis Acute respiratory distress syndrome Metabolic alkalosis Atelectasis

Acute respiratory distress syndrome

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

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

For a client with an endotracheal (ET) tube, which nursing action is the most important? Providing frequent oral hygiene Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours Auscultating the lungs for bilateral breath sounds

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated? Blood pressure increase of 20 mm Hg Vital capacity of 12 mL/kg PaO2 60 mmHg with an FiO2 <40% Heart rate <100 bpm

Blood pressure increase of 20 mm Hg Criteria for terminating the weaning process include heart rate increase of 20 beats/min and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

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

Correct use of incentive spirometry 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.

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? Inform the physician promptly that there is in imminent leak in the drainage system. Document that the chest drainage system is operating as it is intended. Encourage the client to do deep breathing and coughing exercises. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes.

Document that the chest drainage system is operating as it is intended.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Anxiety Decreased cardiac output Impaired gas exchange

Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

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

Encourage breathing exercises Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.

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 try to stop coughing during and after using the spirometer. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Encourage the patient to take approximately 10 breaths per hour, while awake. Have the patient lie in a supine position during the use of the spirometer.

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

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Encouraging increased fluid intake Maintaining a cool room temperature Elevating the head of the bed 30 degrees

Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Hemorrhage Damage to surrounding tissues Lung contusion Fibrotic changes in lungs

Fibrotic changes in lungs For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

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 manage the need for fluid restriction How to splint the incision when coughing How to milk the chest tubing How to take prophylactic antibiotics correctly

How to splint the incision when coughing

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 Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Initiate oxygen therapy. Administer analgesics as ordered. Perform nasopharyngeal suctioning. Administer a heparin bolus and begin an infusion at 500 units/hour.

Initiate oxygen therapy.

Which type of lung cancer is characterized as fast growing and tends to arise peripherally? Squamous cell carcinoma Bronchoalveolar carcinoma Adenocarcinoma Large cell carcinoma

Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and usually grows slowly. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? Progressive loss of lung function associated with chronic disease Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function with history of normal lung function

Progressive loss of lung function associated with chronic disease

A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize? Notify the physician that the client needs a referral to a psychiatrist. Provide emotional support to the client and family. Place a referral for a social worker to visit the client. Schedule a visit to the client's primary physician within 24 hours.

Provide emotional support to the client and family

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 there are leaks in the system. See if the chest tube is clogged. See if the wall suction unit has malfunctioned. See if a kink has developed in the tubing.

See if there are leaks in the system.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? Tense and relax muscles in the lower extremities. Wear tight-fitting clothing. Begin estrogen replacement. Consume the majority of daily fluid intake prior to bed.

Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin B6 Vitamin E Vitamin C Vitamin D

Vitamin B6

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

Volume-controlled With volume-controlled 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.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: follow up with the physician in 2 weeks. maintain fluid intake of 40 oz (1,200 ml) per day. continue to take antibiotics for the entire 10 days. turn and reposition himself every 2 hours.

continue to take antibiotics for the entire 10 days. The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

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 Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as hemothorax. pleural effusion. consolidation. pneumothorax.

pleural effusion. Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.