hesi resp

When the chest tube is removed, the client is asked to perform the Valsalva maneuver

(take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place

The clinic nurse administers a tuberculin (Mantoux) skin test to a client. The nurse tells the client to return to the clinic for reading the results in how long?

48 to 72 hours

The nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply.

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication?

A kink in the ventilator circuit

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

Activities should be resumed gradually. Avoid contact with other individuals, except family A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs during suctioning.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward.

The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

he nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus moving from smaller airways to larger ones to support expectoration of the mucus.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?

Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

The nurse is assessing the functioning of a chest tube drainage system Which are the expected assessment findings? Select all that apply.

Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

typical early manifestations of pulmonary sarcoidosis

Dry cough and dyspnea

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

Histoplasmosis is an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS).

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?

Foods that are highly seasoned are irritating to the throat and should be avoided. The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat

A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism?

Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem

Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber

If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action.

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening.

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions when performing this procedure? Select all that apply.

Keeping a supply of suction catheters at the bedside Auscultating breath sounds to determine the need for suctioning Hyperoxygenating the client before, during, and after suctioning

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care

Particulate respirator, gown, and gloves

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply.

Pressure support is added to the oxygen system. The T-piece is connected to the client's artificial airway. The client is removed from the mechanical ventilator for a short period of time. n. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination

notes that the client has absence of breath sounds in the right upper lobe of the lung

Right pneumothorax

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate?

Stop the procedure and reoxygenate the client.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.

Suctioning the client as needed Encouraging coughing every 2 hours Supporting the neck incision when the client coughs Monitoring the respiratory status frequently as prescribed

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for 1½ weeks. The nurse determines that the client has understood the information if the client makes which statement?

The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.

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?

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.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?

The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis

A client diagnosed with tuberculosis is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

The client with tuberculosis has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit

The nurse is assessing a client with the typical clinical manifestations of tuberculosis. The nurse should expect the client to report having fatigue and cough that have been present for how long?

The client with tuberculosis may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

Following removal of the endotracheal tube the nurse monitors the client for respiratory distress.

The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstructio

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is inserted. Based on this assessment, which action is most appropriate?

The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, the suction is not working properly, or the lung has re-expanded

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client?

This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain.

The nurse is monitoring the function of a client's chest tube that is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water-seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

When the chest tube is patent, the fluid in the water-seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling, and indicates proper function of the system.

Tidal volume

is the amount of air delivered with each set breath on the mechanical ventilator

Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness;

levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

pulmonary sarcoidosis. Later manifestations include

night sweats, fever, weight loss, and skin nodules.

a chest tube inserted notes continuous gentle bubbling in the suction control chamber.

this is an expected finding