Exam3 Study Questions

A nurse assesses a newly admitted client with a diagnosis of pulmonary TB. Which clinical findings support this diagnosis? Select All That Apply. 1. Fatigue 2. Polyphagia 3. Hemoptysis 4. Night Sweats 5. Black tongue

1. Fatigue 3. Hemoptysis 4. Night Sweats

A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A. urticaria B. stridor C. tachypnea D. angioedema

B. stridor

The nurse should refer a client to the pulmonary clinic for suspected TB based on which clinical indicators reported during the initial client interview? Select All That Apply. 1. Vomiting 2. Chest Pain 3. Hemoptysis 4. Night Sweats 5. Bilateral Crackles

3. Hemoptysis 4. Night Sweats

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration? A client who has a chest tube following a fall from a ladder A client who had a hemi-colectomy and placement of a colostomy A client receiving continuous enteral feeding through NG tube A client who Crohn's disease and has an ileostomy

A client receiving continuous enteral feeding through NG tube Rationale: A client who is receiving continuous enteral feedings through an NG tube is at greatest risk for aspiration, because if the tube slips into the lungs the feeding can enter the lungs. The nurse should confirm placement of the NG tube after inserting and before initiating enteral feedings. The nurse should confirm initial placement with an x-ray and subsequently, check by aspirating stomach contents and measuring the pH of the fluid. The aspirate should have a pH of 1 to 4, or as high as 6 if receiving medication that controls gastric acid.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environment A room with another nonsurgical client A room in the ICU A room that is within view of the nurses' station

A room with air exhaust directly to the outdoor environment Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? Medications will need to be taken for the rest of the client's life, even if the client feels better. Medications will need to be taken until the Mantoux test is negative. A typical course of treatment involves 6 to 9 months of consistent medication use. The client's family will also need to take medications to prevent infection.

A typical course of treatment involves 6 to 9 months of consistent medication use. Rationale: Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.

A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time would it be best for the nurse to collect the sample? A. First thing in the morning B. After a period of exercise C. At bedtime D. Immediately after a meal

A. First thing in the morning

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.) A. Mask B. Close door C. Isolation gown D. Throw sharps away E. Wear gloves F. Wash hands

A. Mask B. Close door D. Throw sharps away F. Wash hands

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A. auscultate lung fields B. assess pulse and respirations C. assess characteristics of her sputum D. instruct to slowly exhale with pursed lips

A. auscultate lung fields

The nurse is preparing to auscultate a client's lungs. Which of the following breath sounds would be considered abnormal? Select all that apply. a. Crackles b. Vesicular c. Bronchovesicular d. Wheezes e. Bronchial

a. Crackles d. Wheezes

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of prophylactic antibiotics Administration of pneumococcal vaccine to vulnerable individuals Obtaining culture and sensitivity swabs from all newly admitted clients Administration of antiretroviral medications to clients over age 65

Administration of pneumococcal vaccine to vulnerable individuals

The nurse is caring for a client with a chest tube. The nurse understands that continuous air bubbling in the water-seal chamber may indicate which situation? 1. air is passing out of the pleural space 2. air is being removed from within the lung tissue 3. air is leaking into the drainage system 4. such bubbling is expected

Air is leaking into the drainage system ; make sure all connections are tight and taped.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? Increase the oxygen flow to 3 L/min. Assess the client's respiratory status. Call emergency services for the client. Have the client cough and expectorate secretions.

Assess the client's respiratory status.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? Auscultate lung fields. Assess pulse and respirations. Assess characteristics of her sputum. Instruct to slowly exhale with pursed lips

Auscultate lung fields.

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? Constipation Black colored stools Staining of teeth Body secretions turning a red color

Body secretions turning a red color

A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client? Calcium channel blockers Angiotensin-converting enzyme inhibitor Beta-blockers Angiotensin receptor blockers

Calcium channel blockers

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported? Hot, flushed feeling Sudden chills and fever Chest pain that occurs suddenly Dyspnea when deep breaths are taken

Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

A child with a pneumothorax has a chest tube attached to a water seal system. When assessing the child, the nurse notices that the chest tube has become disconnected from the drainage system. What would the nurse do first? Notify the health care provider. Apply an occlusive dressing. Clamp the chest tube. Perform a respiratory assessment.

Clamp the chest tube. Rationale: If a chest tube becomes disconnected from the water seal drainage system, the nurse would first clamp the chest tube to prevent air from entering the child's chest cavity. Then the nurse would perform a respiratory assessment and notify the health care provider. An occlusive dressing would be applied first if the chest tube became dislodged from the child's chest.

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

A nurse is planning to prioritize client care after receiving report and rounded on assigned patients. Which of the following client's is a high priority for the nurse to see first? A. a client who is ambulatory and going for an x-ray at 10am B. a client who is to be discharged at 11am C. a client who received pain medication 30 min ago D. a client who is SOB

D. a client who is SOB

The parent of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The parent tells the nurse that the child complains of discomfort on the right side and that ibuprofen is ineffective. Which instruction would the nurse provide to the parent? Increase the dose of ibuprofen. Increase the frequency of ibuprofen. Encourage the child to lie on the left side. Encourage the child to lie on the right side.

Encourage the child to lie on the right side. Rationale: Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the parent to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? Ask the x-ray technician to come to the client's room to obtain a portable x-ray. Have the client wear a mask. Notify the x-ray department that the client requires airborne precautions. Wear a filtration mask and gloves during transport.

Have the client wear a mask.

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? Review laboratory test results for low hemoglobin. Observe for signs of infection. Monitor the mouth for signs of xerostomia. Examine the skin for generalized urticaria.

Observe for signs of infection. Rationale: Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.

An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care? A) Suction the patient's airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.

Suction the patient's airway secretions. Feedback: As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect? Tachypnea Hypothermia Bradycardia Pulse deficit

Tachypnea Rationale: A respiratory infection, such as pneumonia, can cause an increase in respiratory rate.

The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action? Teach the client to splint the rib cage Teach the client deep-breathing and coughing exercises Contact the respiratory therapist promptly Teach the client pursed lip breathing

Teach the client to splint the rib cage Rationale: Because the client has pain on inspiration, the nurse educates the client to use the hands or a pillow to splint the rib cage while coughing. Deep breathing and coughing would cause more pain, and pursed lip breathing would provide relief. The client is not in obvious respiratory distress, so there is no immediate need to contact the respiratory therapist.

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? Pertussis Methicillin-resistant Staphylococcus aureus Mycoplasma pneumonia Tuberculosis

Tuberculosis

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

b. Flail chest

While assessing the client, the nurse notes that the client has a moist cough. The nurse would include which of the following questions in the focused interview? a. "Have you been losing weight?" b. "How long have you been sick?" c. "Are you wheezing?" d. "Are you coughing up any mucus or phlegm?"

d. "Are you coughing up any mucus or phlegm?"

A client reports dyspnea, fatigue, and having had a persistent productive cough for the last few months, which the client attributes to a bout with the flu. The nurse suspects that this client may have: lung cancer. pleurisy. pleural effusion lung abscess.

lung cancer.

A hospitalized child suddenly begins reporting "my chest hurts," is tachypneic, and has tachycardia. The nurse auscultates the lung sounds and finds absent breath sounds on one side. After notifying the health care provider, what action would the nurse take first? prepare for chest tube insertion administer oxygen obtain an oxygen saturation measurement prepare for mechanical ventilation

prepare for chest tube insertion

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer? "My cough has changed from a dry cough to one with lots of sputum production." "I've had a low-grade fever for 2 weeks." "My voice is hoarser than it used to be." "I've lost 10 pounds in the last month."

"My cough has changed from a dry cough to one with lots of sputum production." Rationale: A cough that changes in character is one of the hallmark signs of lung cancer. Low-grade fever, hoarseness, and weight loss may be attributed to other disease processes and don't necessarily indicate lung cancer. 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 TUMORS, Lung Cancer (Bronchogenic Carcinoma), p. 579.

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patient's level of consciousness (LOC). B) Assess the patient's extremities for signs of cyanosis. C) Assess the patient's oxygen saturation level. D) Review the patient's hemoglobin, hematocrit, and red blood cell levels.

Assess the patient's oxygen saturation level. Feedback: The effectiveness of the patient's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patient's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A nurse collecting data from a client who is 2 days postop auscultates bilateral breath sounds but absent breath sounds in the bases. The nurses should suspect which of the following postop complications. 1. Atelectasis 2. Rales 3. Rhonchi 4. Pneumothorax

Atelectasis ; incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism

Atelectasis Feedback: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats. Secure the oxygen tubing to the bed sheet near the client's head. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Attach a humidifier bottle to the base of the flow meter.

A nurse is administering 100% oxygen to a child with a pneumothorax based on the understanding that this treatment is used primarily for which reason? A. Improve gas exchange B. Bypass the obstruction C. Hasten air reabsorption D. Prevent hypoxemia

C. Hasten air reabsorption Rationale: Administration of 100% oxygen is used to treat pneumothorax primarily because it hastens the reabsorption of air. Generally this is used only for a few hours. Although the oxygen also improves gas exchange and prevents hypoxemia, these are not the reasons for its use in this situation. There is no obstruction with a pneumothorax.

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? Unequal pupils Hypertension Tympany upon chest percussion Confusion

Confusion Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration? 1. continue to monitor the client 2. immediately notify the provider 3. reposition the client toward the left side 4. clamp the chest tube near the water seal

Continue to monitor the client ; the fluid in the water seal chamber rises 2-4 inches during inhalation and falls during exhalation

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? Ask the x-ray technician to come to the client's room to obtain a portable x-ray. Have the client wear a mask. Notify the x-ray department that the client requires airborne precautions. Wear a filtration mask and gloves during transport.

Have the client wear a mask. Rationale: When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? Furosemide Dexamethasone Heparin Atropine

Heparin Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? Loud, scratchy sounds Squeaky, musical sounds Popping sounds Snoring sounds

Loud, scratchy sounds Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? Encourage fluid intake of 1500 mL/day. Position head of the bed at 10 degrees. Cough and deep breathe every 8 hr. Obtain a sputum culture.

Obtain a sputum culture.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding? Slow, deep respirations Rapid, deep respirations Paradoxical respirations Pain, especially with inspiration

Pain, especially with inspiration Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include shallow respirations, splinting or guarding the chest protectively to minimize chest movement, pain, and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, and possible bruising at the fracture site. Paradoxical respirations are seen with a flail chest.

A nurse is caring for a 68 year old female client who has been diagnosed with a cerebrovascular accident. The client is still unconscious, requiring mechanical ventilation. Which of the following measures is critical to minimize the risk of ventilator-associated pneumonia in this client? Give antibiotics as prophylaxis Change the ventilator circuits daily Place the client is a semi-Fowlers position Turn the client from side to side every four hours

Place the client is a semi-Fowlers position Rationale: Placing the client in this position with head of bed 30-45 degrees reduces the risk of aspiration. minimizing the risk of infection from pathogens

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure? A sternal incision A chest tube Moderate pain Pulmonary function studies

A chest tube Rationale: A lobectomy is major surgery that involves a large posterolateral or anterolateral incision into bone, muscle, and cartilage. Chest tubes are placed to drain air and fluid and remain in place for several days postoperatively.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. clamp the chest tube prior to transferring the client to a wheelchair B. Disconnect the chest tube from the drainage system during transport C. Keep the Drainage system below the level of the client's chest at all times D. Empty the collection chamber prior to transport

C. Keep the Drainage system below the level of the client's chest at all times

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? Encourage the client to ambulate frequently. Encourage coughing and deep breathing. Encourage the client to increase fluid intake. Encourage regular use of the incentive spirometer.

Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? Maintaining a semi-Fowler's position as often as possible Administering oxygen via nasal cannula at 2 L/min Helping the client select a low-salt diet Encouraging the client to drink 2 to 3 L of water daily

Encouraging the client to drink 2 to 3 L of water daily

When a patient with tuberculosis (TB) is being pre-pared for discharge, which statement by the patient indicates a need for further teaching? "Everyone in my family needs to go and see the doctor for TB testing." "I will continue to take my isoniazid until I am feeling completely well." "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." "I will change my diet to include more foods rich in iron, protein, and vitamin C."

"I will continue to take my isoniazid until I am feeling completely well." Rationale: Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing and placing tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB

A postoperative client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Acute respiratory distress syndrome (ARDS) Atelectasis Aspiration Pulmonary embolism

Atelectasis Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? Initiate chest physiotherapy. Immobilize the ribs with an abdominal binder. Prepare the client for surgery. Immediately sedate and intubate the client.

Initiate chest physiotherapy. Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury. 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, Flail Chest, p. 591.

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicates a complication that requires notifying the provider immediately? 1. serosanguineous drainage from puncture site 2. discomfort at puncture site 3. increased heart rate 4. decreased temperature

Increased heart rate ; clients can develop pulmonary edema or cardiovascular distress after mediastinal content shift suddenly.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? Pulmonary hypertension Chronic obstructive pulmonary disease (COPD) Empyema Pulmonary tuberculosis

Pulmonary hypertension

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? Increase the client's wall suction. Strip the client's chest tube. Clamp the client's chest tube. Reposition the client.

Reposition the client. Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia? The nurse should elevate the head of the client's bed to30-45 degrees. The nurse should ensure the patient remains sedated. Instruct the client to tilt their head back while swallowing. Turn on the television for the client during meals.

The nurse should elevate the head of the client's bed to30-45 degrees.

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the UAP? 1. Teaching the patient about the importance of adequate fluid intake and hydration. 2. Assisting the patient to a sitting position with neck flexed, shoulder relaxed, and knees flexed. 3. Reminding the patient to use an incentive spirometer every one to two hours while awake. 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession.

3. Reminding the patient to use an incentive spirometer every one to two hours while awake.

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? 1. increase the client's wall suction 2. strip the client's chest tube 3. clamp the client's chest tube 4. reposition the client

4. reposition the client

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? Auscultate lung fields. Assess pulse and respirations. Assess characteristics of her sputum. Instruct to slowly exhale with pursed lips.

Auscultate lung fields. Rationale: The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider right away? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decrease temperature

C. Increased heart rate

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding? Select all that apply. a. Atelectasis b. Chronic bronchitis c. Lobar pneumonia d. Pleural effusion e. Congestive heart failure

a. Atelectasis c. Lobar pneumonia d. Pleural effusion

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

a. Continuous bubbling in the water-seal chamber

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? a. Blockage of the ET tube by the client's tongue b. Passage of the ET tube into the esophagus c. Movement of the ET tube into the right main bronchus d. Infection of the vocal cords

c. Movement of the ET tube into the right main bronchus

The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions? a. Pneumonia b. Atelectasis c. Pneumothorax d. Pleural effusion

c. Pneumothorax

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A.Give morphine IV. B.Administer oxygen therapy. C.Start an IV infusion of lactated Ringer's. D.Initiate cardiac monitoring.

B.Administer oxygen therapy.

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect? Dullness percussed over the client's lung fields. Crepitus palpated on the client's chest. Crackles auscultated over the client's lung fields. Substernal retractions noted on the client's chest.

Dullness percussed over the client's lung fields .Rationale: Areas of dullness percussed over the client's lung fields indicates areas of fluid in the lung. This is an expected finding for a client who has a pleural effusion.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? Give morphine IV. Administer oxygen therapy. Start an IV infusion of lactated Ringer's. Initiate cardiac monitoring.

Administer oxygen therapy. Rationale: The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? Apnea Dysphagia Hypoxemia Pleural effusion

Hypoxemia Rationale: The nurse can expect to find the client with hypoxemia, which is decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange.

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? Movement of the trachea toward the unaffected side Bubbling of the water in the water seal chamber with exhalation Crepitus in the area above and surrounding the insertion site Eyelets are not visible

Movement of the trachea toward the unaffected side Rationale: A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? Oxygen saturation of 95% No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? Encourage fluid intake of 1500 mL/day. Position head of bed at 10 degrees. Cough and deep breathe every 8 hr. Obtain a sputum culture.

Obtain a sputum culture. Rationale: The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

Pneumothorax Feedback: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia.

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis? A) The patient is experiencing painless hemoptysis. B) The patient's arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing. C) The patient's oxygen saturation level is below 88%, but he denies shortness of breath. D) The patient's pain intensifies when he coughs or takes a deep breath.

The patient's pain intensifies when he coughs or takes a deep breath. Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

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 Air-leak chamber Collection chamber Suction control chamber

Water-seal chamber Rationale: Fluctuations in the water-seal compartment are called tidal movements and indicate the normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not the chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest

The nurse is caring for an 11-year-old child with pneumonia who is exhibiting an increased work of breathing. Which intervention is the priority? positioning the child in Fowler's position administering intravenous fluids as prescribed providing supplemental oxygen as prescribed administering analgesics as prescribed

positioning the child in Fowler's position Rationale: Positioning the child in Fowler position helps to open the airway and provide more room for lung expansion, resulting in more effective breathing patterns while supplemental oxygen and intravenous fluids are administered. Administering intravenous fluids and administering oxygen are appropriate actions after the child is placed in a comfortable position. Analgesics may be prescribed and administered if the child is experiencing pain from coughing. Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 40: Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder, Pneumonia, p. 1431.