Group B HESI Respiratory Questions

Morgan A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is: A. High and expected B. Low and unexpected C. Normal and expected D. Uncertain and unexpected

ANSWER: C The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is non-cardiac.

Vivica A nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which of the following is the appropriate action? A. Change the chest tube drainage system B. Document the findings C. Check for an air leak D. Notify the physician

Answer: B. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected.

Tori While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? A. Call the health care provider to reinsert the tube. B. Grasp the retention sutures to spread the opening. C. Call the respiratory therapy department to reinsert the tracheotomy. D. Cover the tracheostomy site with a sterile dressing to prevent infection.

Answer: B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.

Monica A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? A. Electrolyte levels B. Coagulation times C. Liver enzyme levels D. Serum creatinine level

Answer: C Isoniazed therapy cause an elevated hepatic enzyme levels and hepatitis. Therefore, liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in clients who are older than 50 or abuses alcohol.

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

Answer: C. The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most common is dyspnea which is accompanied by an increased respiratory rate, Other typical symptoms or pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis

Vivica A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan? A. Position the client in semi-Fowler's position B. Add water to the suction chamber as it evaporates C. Tape the connection sites between the chest tube and the drainage system D. Instruct the client to avoid coughing and deep breathing

Answer: D. It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung re-expansion. Water is added to the suction chamber as it evaporate to maintain full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection. The client is positioned in Semi-Fowler's position to facilitate ease in breathing.

Vivica A nurse is suctioning an unconscious client who has a tracheostomy. The nurse need to avoid which of the following actions when performing this procedure? A. Keeping a supply of suction catheters at the bedside B. Auscultating breath sounds to determine the need for suctioning C. Hyperoxygenating the client before, during and after suctioning D. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

Answer: D. Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently as needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and rise intracranial pressure.

Alyson The nurse is planning care for a client with a chest tube attached to a chest drainage system. The nurse plans which action(s) as part of routine chest tube care? Select all that apply. A. Encouraging the client to cough and deep breathe B. Adding water to the suction chamber as it evaporates C. Keeping the collection chamber below the client's waist D. Clamping the chest tube when the client gets out of bed E. Taping the connection between the chest tube and the drainage system

Answer: a,b,c,e Rationale: To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy. The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from re-entering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.

Theresa The nurse is caring for a client after a bronchoscopy and biopsy. which finding, if noted in the client should be reported immediately to the health care provider? A. Dry cough B. Hematuria C. bronchospasm D. blood streaked sputum

C is the correct answer. if a biopsy was performed during a bronchoscopy, blood streaked sputum is expected for several hours. frank blood indicates hemorrhage. a dry cough may be expected. the client should be assessed for signs/symptoms of complications which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. hematuria is unrelated to this procedure.

Emily Which nursing intervention should be implemented before the deflation of a tracheostomy cuff? A. Have the obturator available. B. Take a pulse oximetry reading. C. Suction the trachea and mouth. D. Encourage deep breathing and coughing.

Rationale: C is correct because secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.