Med-Surge: Respiratory

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? Nasal edema Mouth breathing Periorbital ecchymosis Frequent swallowing

Frequent swallowing Rationale: Frequent swallowing indicates posterior nasal bleeding and possibly hemorrhage. The nurse should notify the surgeon promptly about this finding.

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? SATA NPO status Alternative methods of communication Endotracheal intubation Changes in body image Swallowing exercises

NPO status Alternative methods of communication Changes in body image Swallowing exercises Rationale: The client will receive fluids and nutrition via an enteral tube while healing from the surgery. Radical neck dissection interrupts vocal communication, so the nurse should determine with the client and family how the client will prefer to communicate. Extensive resection can result in some disfigurement and permanent tracheostomy; the nurse should help prepare the client for these changes. Swallowing can be challenging after an extensive resection. The client might require the assistance of a speech-language pathologist to provide swallowing exercises and techniques.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record the nurse notes a history of COPD. Which of the following oxygen-delivery methods should the nurse plan to use for this client? Simple face mask Non Rebreather mask Bag-valve-mask device Nasal cannula

Nasal cannula Rationale: A nasal cannula delivers precise concentrations of O2; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a PE? Stabbing chest pain Calf tenderness Elevated temperature Bradycardia

Stabbing chest pain Rationale: A manifestation of a PE is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? To encourage deep breaths To mobilize secretions in the airways To dilate the bronchioles To stimulate the cough reflex

To mobilize secretions in the airways Rationale: The purpose of chest physiotherapy is to loosed and promote the drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (SATA) Tracheal deviation to the left Temp of 102 Absent breath sounds on the right side Neck vein distention Bradypnea

Tracheal deviation to the left Absent breath sounds on the right side Neck vein distention Rationale: A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty increases, the blood flow return compresses, causing the neck veins to distend.

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? "I can keep my dentures in during the procedure." "I am allowed only clear liquids prior to the procedure." "A tissue sample might be obtained during the procedure." "A signed consent form is not required fro this procedure."

"A tissue sample might be obtained during the procedure." Rationale: The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing.

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicated that the client understands the impact of the surgery? "I'm not going to be able to cough for a while after the surgery" "After I recover from the anesthesia, I'll be able to eat regular food again" "After the surgery, my voice will gradually return but might be weak" "I understand that I will have permanent tracheostomy after the surgery"

"I understand that I will have permanent tracheostomy after the surgery" Rationale: With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent.

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? "After the surgeon removes the lung, you will not need to cough." "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." "I will show you how to splint your incision while coughing."

"I will show you how to splint your incision while coughing." Rationale: A client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint the incision to reduce pain when coughing.

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? "I'll expect a little leg swelling since I won't be that active for a while. " "I'll see the doctor every week to change my vena cava filter." "I'll call the doctor if I see any blood in my urine or stool." "I'll have to take the blood thinner for a few more days."

"I'll call the doctor if I see any blood in my urine or stool." Rationale: Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately.

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? "Apply warm compresses to the face" "Take aspirin 650 mg PO for mild pain" "Close your mouth when sneezing" "Lie on your back with your head elevated 30* when resting"

"Lie on your back with your head elevated 30* when resting" Rationale: The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? "Two tubes were necessary due to excessive bleeding from the area of the surgery." "The tubes drain blood from 2 different lung areas." "The lower tube will drain blood, and the higher tube will remove air." "The second tube will take over if blood clots block the first tube."

"The lower tube will drain blood, and the higher tube will remove air." Rationale: The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air.

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? "Be sure to take cough medicine to avoid coughing." "Try to drink at least 2 to 3 liters of fluid per day." "Try to reduce your smoking to 2 cigarettes per day." "Be sure to eat 3 full meals each day."

"Try to drink at least 2 to 3 liters of fluid per day." Rationale: Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions.

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? "I'll inhale slowly through pursed lips to help me breathe better." "When I do my pursed-lip breathing, I'll lie down first." "When I breathe out through pursed lips, my airways don't collapse between breaths." "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

"When I breathe out through pursed lips, my airways don't collapse between breaths." Rationale: Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for client who have emphysema. The client should use this technique during physical activity and episodes of dyspnea.

A nurse in a clinic is providing teaching for a client who is scheduled to have a TB test. Which of the following pieces of information should the nurse include? "If the test is positive, it means you have an active case of TB" "If the test is positive, you should have another TB test in 3 weeks" "You must return to the clinic to have the test read in 2 or 3 days" "A nurse will use a small lancet to scratch the skin of your forearm before applying the TB substance"

"You must return to the clinic to have the test read in 2 or 3 days" Rationale: The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to TB. If the client does not return to have the test read within 72 hours, another TB test is necessary.

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (SATA) "You will have a chest tube in place after surgery." "We'll frequently help you turn, cough, and breathe deeply after surgery." "You will have to remain in bed for about 2 days after the surgery." "We'll give you oxygen to support your breathing if you need it." "You should expect pain for the first few days after surgery."

"You will have a chest tube in place after surgery." "We'll frequently help you turn, cough, and breathe deeply after surgery." "We'll give you oxygen to support your breathing if you need it." Rationale: After a pneumonectomy, some client have a clamped chest tube briefly to help reduce mediastinal shift. They do not usually have closed-chest drainage. Helping the client turn, cough, and breathe deeply is standard preventive postoperative care after thoracic surgery. After thoracic surgery, clients typically receive oxygen by nasal cannula or mask for the first 2 days and then as needed.

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A client who has a chest tube following a pneumothorax A client who has an acute exacerbation of Crohn's disease A client who is postoperative following a laparoscopic appendectomy A client who is recovering from thyroid storm

A client who has a chest tube following a pneumothorax Rationale: Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? Excessive airway secretions A leak within the ventilator's circulatory Decreased lung compliance The client coughing or attempting to talk

A leak within the ventilator's circulatory Rationale: The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.

A nurse in the ED is assessing a client for closed pneumothorax and significant bruising to the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? Absence of breath sounds Expiratory wheezing Inspiratory stridor Rhonchi

Absence of breath sounds Rationale: A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? Eliminating environmental triggers that precipitate attacks Addressing the client's perception of the disease process and what might have triggered past attacks Overviewing the client's medication regimen Explaining manifestations of respiratory infections

Addressing the client's perception of the disease process and what might have triggered past attacks Rationale: Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? Aspiration of water Infection of the stoma Bleeding around the stoma Skin breakdown around the stoma

Aspiration of water Rationale: The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (SATA) Assign the client to a private room with negative-pressure airflow. Add contact precautions to the client's plan of care Wear an N95 respirator when entering the client's room Ensure the client's environment provides 4 exchanges of fresh air per minute Institute protective environment precautions as soon as the client arrives on the unit

Assign the client to a private room with negative-pressure airflow Wear an N95 respirator when entering the client's room Rationale: This client's history and present status suggest tuberculosis (TB), a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room.

A client comes to the emergency department in severe respiratory distress following left-seded blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? Tracheostomy placement Thoracentesis CT scan of the chest Chest tube insertion

Chest tube insertion Rationale: The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? Measuring heart rate Palpating peripheral pulses Observing sputum for blood Confirming the gag reflex

Confirming the gag reflex Rationale: The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk.

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? Friction rub Crackles Crepitus Tactile fremitus

Crepitus Rationale: Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue which is often a clinical manifestation of pneumothorax.

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? Discuss ways the client can reduce the number of cigarettes smoked per day Suggest the client switch from smoking cigarettes to smoking a pipe Inform the client that treatment will be ineffective if smoking continues Discourage the use of nicotine gum

Discuss ways the client can reduce the number of cigarettes smoked per day Rationale: The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually.

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? Removing air from the pleural space Creating access for irrigating the chest cavity Evacuating secretions from the bronchioles and alveoli Draining blood and fluid from the pleural space

Draining blood and fluid from the pleural space Rationale: The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? Dry cough Rhinitis Sore throat Swollen lymph nodes

Dry cough Rationale: A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? Eat high-calorie foods first Increase intake of water at meal times Perform active ROM exercises before meals Keep saltine crackers nearby for snacking

Eat high-calorie foods first Rationale: Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? Provide chest physiotherapy Perform oropharyngeal suction Encourage deep-breathing and coughing Assist the client with ambulation

Encourage deep-breathing and coughing Rationale: The first action the nurse should take when using the (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? Insert a large-bore IV catheter Ensure an adequate airway Obtain an accurate medication history Prepare to administer an antagonist

Ensure an adequate airway Rationale: The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opioid toxicity.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? Instruct the client to cough Administer oxygen via face mask Evaluate the client for stridor Keep the client in a semi to high-Fowler's position

Evaluate the client for stridor Rationale: The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (SATA) Explain that the client will receive sedation and will not remember the procedure Verify that the client understands the purpose and nature of the procedure Offer the client sips of clear liquids until 1 hr before the test Obtain a pre-procedural sputum specimen Instruct the client to keep his neck in a neutral position

Explain that the client will receive sedation and will not remember the procedure Verify that the client understands the purpose and nature of the procedure Rationale: For bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? Place the drainage system at the head of the client's bed Increase the suction to the chest drainage system Place the client on low-flow oxygen via nasal cannula Immerse the end of the chest tube in a bottle of sterile water

Immerse the end of the chest tube in a bottle of sterile water Rationale: If the chest tube and drainage system have become disconnected, air can enter the pleural space, producing a pneumothorax that can result in severe respiratory distress. To prevent a pneumothorax from developing, a temporary water seal can be established by immersing the end of the chest tube in an open bottle of sterile water. This allows air to escape and not enter the pleural space. A bottle of sterile water should always be ready available at the bedside for a client who has a chest tube.

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via NC. The client is dyspneic and has an oxygen saturation via pulse ox of 85%. Which of the following actions should the nurse take? Place a non-rebreather mask on the client and increase the oxygen flow to 3 L/min Prepare the client for possible endotracheal intubation and mechanical ventilation Increase the oxygen flow and request an ABG determination Position the client supine and administer an anti-anxiety medication

Increase the oxygen flow and request an ABG determination Rationale: The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88-92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via a pulse ox.

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? Increased coughing Diaphragmatic breathing Hemoptysis Kussmaul respirations

Increased coughing Rationale: The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? Initiate bag-valve-mask ventilation Provide the client with a communication board Obtain a blood sample for ABG analysis Document the ventilator settings

Initiate bag-valve-mask ventilation Rationale: Using ABC priority-setting-framework the nurse should first provide ventilations with a bag-valve-mask device.

A nurse is assessing a client who has pharyngitis. Which of the following finding is the nurse's priority to report to the provider? Elevated temperature Swollen cervical lymph nodes Inspiratory stridor Purulent nasal discharge

Inspiratory stridor Rationale: The nurse should determine that the priority finding is inspiratory stridor, which is a manifestation of airway obstruction. The nurse should notify the rapid response team and administer humidified oxygen.

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? Cover the insertion site with hydrocolloid dressing after removal Provide pain medication immediately after removal Instruct the client to perform the Valsalva maneuver during removal Delegate removal of the chest tube to a LPN

Instruct the client to perform the Valsalva maneuver during removal Rationale: The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space.

A nurse is caring for a client who has a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? The client will need intensive smoking-cessation education After surgery, the prognosis for clients with lung cancer is usually good Lung cancer usually has metastasized before the client presents with symptoms Oxygen therapy is ineffective following a lobectomy

Lung cancer usually has metastasized before the client presents with symptoms Rationale: The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short-term and long-term care options for the client.

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? Lymph nodes Maxillary sinuses Intercostal spaces Salivary glands

Maxillary sinuses Rationale: Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination.

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis (TB)? Pericardial friction rub Weight gain Night sweats Cyanosis of the finger

Night Sweats Rationale: Night sweats and fevers are clinical manifestations of TB.

A nurse is assessing a client who has a positive TB test. Which of the following findings indicates that the client has active TB? Rhinitis Air hunger Night sweats Weight gain

Night sweats Rationale: Manifestations of active TB include a fever, coughing, night sweats, anorexia, and fatigue.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? Soft blowing Loud bubbling Dry grating Noisy wheezing

Noisy wheezing Rationale: Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? Tympanic temperature 100.4*F PaO2 50 mmHg Rhonchi Hypopnea

PaO2 50 mmHg Rationale: This client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? Hyperventilate the client with 100% oxygen prior to obtaining the specimen Apply ice to the site after obtaining the specimen Perform an Allen's test prior to obtaining the specimen Release the pressure applied to the puncture site 1 min after the needle is withdrawn

Perform an Allen's test prior to obtaining the specimen Rationale: The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is caring for a client who has COPD and is experiencing shortness of breath. Which of the following actions should the nurse perform first? Monitor the client's arterial blood gas results Instruct the client to perform controlled coughing Teach the client how to use pursed-lip breathing Place the client in an upright position

Place the client in an upright position Rationale: The nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impending airflow.

A nurse is providing instructions about pursed-lip breathing for a client who has COPD with emphysema. This breathing technique accomplishes which of the following? Increases 02 Promotes CO2 elimination Uses the intercostal muscles Strengthens the diaphragm

Promotes CO2 elimination Rationale: A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves CO2 out of the lungs more efficiently.

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Respiratory acidosis Rationale: Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27, and HCO3 25. The nurse should identify that the client has which of the following acid-base imbalances? Respiratory acidosis Metabolic acidosis Respiratory alkalosis Metabolic alkalosis

Respiratory alkalosis Rationale: Because of rapid breathing, the client is exhaling excessive amount of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? Pulmonary edema Tension pneumothorax Flail chest Respiratory obstruction

Respiratory obstruction Rationale: Intercostal retractions and a high-pitched inspiratory noise are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? Lying flat on the affected side Prone with the arms raised over the head Supine with the head of the bed elevated Sitting while leaning forward over the bedside table

Sitting while leaning forward over the bedside table Rationale: When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air.

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? Stridor Coughing Hoarseness Extensive oral secretions

Stridor Rationale: The nurse should identify that stridor is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call RRT for assistance before the airway becomes completely obstructed.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of PE? Sudden onset of dyspnea Tracheal deviation Bradycardia Difficulty swallowing

Sudden onset of dyspnea Rationale: Clinical manifestations of PE have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? Wheezing Bradypnea Tachycardia Diaphoresis

Tachycardia Rationale: Tachycardia, dyspnea, restlessness, headaches, and increased BP are indications of impending respiratory failure.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? Clamp the chest tube if there is continuous bubbling in the water seal chamber Keep the chest tube drainage system at the level of the right atrium Tape all connections between the chest tube and drainage system Empty the collection chamber and record the amount of drainage every 8 hr

Tape all connections between the chest tube and drainage system Rationale: The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? The client is unable to speak The client's airway secretions were last suctioned 2 hr ago The client coughs and exporates a large mucous plug The nurse auscultates coarse in the lung fields

The nurse auscultates coarse in the lung fields Rationale: The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? Hallucinations Pruritus Hand and foot syndrome Tinnitus

Tinnitus Rationale: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? Total lung capacity Vital lung capacity Functional residual capacity Residual volume

Total lung capacity Rationale: Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? Use pursed-lip breathing during periods of dyspnea Limit fluid intake to 1,500 mL per day Practice chest breathing each day Wear home O2 to maintain SaO2 of at least 94%

Use pursed-lip breathing during periods of dyspnea Rationale: The nurse should instruct the client about using pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange.

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? pH 7.31, HCO3- 22, PaCO2- 50 pH 7.48, HCO3- 23, PaCO2- 25 pH 7.32, HCO3- 18, PaCO2- 40 pH 7.49, HCO3- 32, PaCO2- 40

pH 7.49, HCO3- 32, PaCO2- 40 Rationale: The nurse should identify that these laboratory values reflect metabolic alkalosis. The pH and bicarbonate values are greater than the expected reference range, and the PaCO2 is within the expected reference range.