Module 2, Chest Tubes & Respiratory

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. a) using elastic stocking, especially when decreased mobility would promote venous stasis b) instructing the client to move the legs in a 'pumping' exercise c) applying a sequential compression device d) instructing the client to dangle the legs over the side of the bed for 30 min/4x/day e) encouraging a liberal fluid intake

a, b, c, e

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.) a) initially, clear the nose & throat b) use diaphragmatic contractions to aid in the expulsion of sputum c) spit surface mucus & saliva into a sterile specimen container d) rinse with mouthwash prior to providing the specimin e) take a few deep breaths before coughing

a, b, e

A client is being sent home with oxygen therapy. The nurse instructs that a) the client should raise the flow of oxygen if shortness of breath increases b) smoking or a flame is dangerous near oxygen c) the client will not be able to travel with oxygen d) oxygen is addictive and its use must be decreased

b

A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report? a) emphysema b) left sided heart failure c) COPD d) bronchitis

b

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) hyperventilation b) hypoxia c) semiconsciousness d) delirium

b

A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse? a) anxiety b) gas exchange c) impaired mobility d) home care

b

A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effects should the nurse be sure to address in client teaching? a) temporarily increased respiratory secretions b) thrush c) nausea & vomiting d) decreased LOC

b

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows a) brusing b) redness & irritation c) drainage d) tissue sloughing

b

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) see if a kink has developed in the tubing b) see if the wall suction unit has malfunctioned c) see if the chest tube is clogged d) see if there are leaks in the system

b

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. a) need for postural drainage b) chest trauma resulting in pneumothorax c) post thoracotomy d) pleurisy e) spontaneous pneumothorax

b, c, e

A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? a) monitor incentive spirometry volumes b) perform chest auscultation c) monitor pulse oximetry readings d) obtain serial ABG samples

c

A client's spouse states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. What findings would indicate a need for further interventions? a) pale, paper thin skin, O2 at 2mL/min via nasal cannula b) client states, 'it always seems like I just can't catch my breath' c) BP 122/80, HR 116, RR 24, pale & clammy skin, temp 101.3F d) BP 122/82, HR 102, RR 24, noted barrel chest, temp 98.4F

c

The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? a) 10cm b) 5cm c) 20cm d) 15cm

c

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to a) hold the breath for 5 seconds & then exhale b) initially inhale through the mouth c) purse the lips when exhaling air from the lungs d) sit in an upright position only

c

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first: a) intravenous magnesium sulfate b) normal saline 0.9% at 100mL/hr IV c) oral fluid of at least 2500mL/day d) oxygen therapy through a non-rebreather mask

d

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) administering pain medications, frequent repositioning, & limiting fluid intake b) coughing, breathing deeply, frequent repositioning, & using an incentive spirometer c) administering oxygen, coughing, breathing deeply, & maintaining bed rest d) coughing, breathing deeply, maintaining bed rest, & using an incentive spirometer

d

A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan? a) instructing the client to wear a mask at all times b) wearing a gown & gloves when providing direct care c) keeping the door to the client's room open to observe the client d) wearing a disposable particulate respirator that fits snugly around the face

d

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? a) activity intolerance b) excess fluid volume c) acute pain d) ineffective breathing pattern

d

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? a) bradypnea & bradycardia b) nonproductive cough & abdominal pain c) hypertension & lack of fever d) chest pain & dyspnea

d

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? a) air-leak chamber b) collection chamber c) suction control chamber d) water-seal chamber

d

Constant bubbling in the water seal of a chest drainage system indicates which problem? a) tidaling b) increased drainage c) tension pneumothorax d) air leak

d

In general, chest drainage tubes are not indicated for a client undergoing which procedure? a) lobectomy b) wedge resection c) segmentectomy d) pneumonectomy

d

A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he or she will be safe from infecting others approximately how long after initiation of the medication therapy? a) 2-3 weeks after initiation of bacteriocidal drugs b) after completion of 6 months of bacteriocidal drugs c) results vary with each clinet, so it is difficult to predict d) within 48 hours after initiation of bacteriocidal drugs

a

A client is being treated in the ED for respiratory distress coupled with pneumonia. The client has no medical history. However, the client works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which order based on the client's immediate needs? a) admin of antibiotics b) admin of corticosteriods & bronchodilators c) client education: avoidance of irritants like smoke/pollutants d) completion of a 12 lead ECG

a

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? a) respiratory failure b) pneumothorax c) hemothorax d) lung cancer

a

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following? a) regular breathing where the rate & depth increase, then decrease b) periods of normal breathing followed by periods of apnea c) irregular breathing 14-18/min d) period of cessation of breathing

a

The nurse is caring for a client who has been in a motor vehicle accident and the care team suspects that the client has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis? a) the client's pain intensifies when he coughs or takes a deep breath b) the client's O2 sat is below 88% but denies SOB c) the client's ABGs are normal, but he demonstrates increased work of breathing d) the client is experiencing painless hemoptysis

a

The nurse is educating a patient with asthma about preventative measures to avoid having an asthma attack. What does the nurse inform the patient is a priority intervention to prevent an asthma attack? a) preparing a written action plan b) staying in the house if it is too hot or cold c) avoiding exercise and any strenuous activity d) using a long-acting steroid inhaler when an attack is coming

a

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? a) early ambulation b) maintaining the client in a supine position c) administering aspirin with warfarin d) increased dietary intake of protein

a

What is the reason for chest tubes after thoracic surgery? a) draining secretions, air, and blood from the thoracic cavity if necessary b) chest tubes allow air into the pleural space c) chest tubes indicate when lungs have re-expanded by ceasing to bubble d) draining secretions and blood while allowing air to remain in the thoracic cavity if necessary

a

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis? a) pain in the calf b) pain in the feet c) negative Homan's sign d) inability to dorsiflex

a

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)? a) cigarette smoking b) genetic abnormalities c) air pollution d) occupational exposure

a

Which terms means an increase in the red blood cell concentration in the blood? a) polycythemia b) bronchitis c) emphysema d) asthma

a

Which type of chest configuration is typical of a client with COPD? a) barrel chest b) funnel chest c) pigeon chest d) flail chest

a

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply. a) miner b) nurse c) mechanic d) banker e) rock quarry worker f) stone cutter

a, e, f

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a) clamp the chest tube immediately b) place the end of the chest tube in a container of sterile saline water c) secure the chest tube with tape d) apply an occlusive dressing and notify the physician

b

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? a) ateledctasis b) pulmonary embolism

b

An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize? a) the fact that the disease is a lifelong, chronic condition that will affect ADLs b) the importance of adhering closely to the prescribed medication regimen c) the fact that TB is self-limiting, but can take up to two years to resolve d) the need to work closely with the occupational & physical therapist

b

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: a) alprazolam (Xanax) b) albuterol c) morphine d) propranolol

b

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) stripping the chest tube every hour b) measuring & documenting the draining in the collection chamber c) keeping the collection chamber at chest level d) maintaining continuous bubbling in the water-seal chamber

b

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? a) bronchial & capillary circulation b) bronchial & pulmonary circulation c) bronchial & alveolar circulation d) alveolar & pulmonary circulation

b

The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication? a) carefully holds the inhaler upright without shaking it b) positions the inhaler 2 finger widths away from the lips c) holds the breath for 5 seconds after administering the medication d) immediately repeats the second puff after the first

b

The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? a) the family's willingness to care for the client b) signs & symptoms of respiratory complications c) resumption of the client's ADLs d) nutritional status & fluid balance

b

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? a) a resident with severe & deforming RA b) a resident who suffered a severe stroke several weeks ago c) a resident with mid-stage Alzheimer disease d) a 92 year old resident who needs extensive help with ADLs

b

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? a) crackles b) cyanosis c) clubbing of fingers d) restlessness

b

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply. a) respiratory rate of 10/min b) use of accessory muscles to breathe c) hypo-ventilatory breathing pattern d) purulent sputum with frequent coughing e) tympany percussed bilaterally over the lung bases

b, d

A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply. a) decreased dead space b) increased diameter of alveoli ducts c) decreased pulmonary compliance d) increased residual volume e) decreased elasticity of the alveolar sacs f) increased thickness of alveolar sace

b, d, e, f

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? a) the PPD can be read within 12 hours after the injection b) a negative reaction always excludes the diagnosis of TB c) a positive reaction indicated the client has been exposed to the disease d) a positive reaction indicates that the client has active TB

c

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a) helping him communicate b) encouraging him to perform ADLs c) keeping his airway patent d) preventing him from developing an infection

c

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? a) have the patient lie in a supine position during the use of the spirometer b) inform the patient that using the spirometer is not necessary if the patient is experiencing pain c) encourage the patient to try to stop coughing during & after using the spirometer d) encourage the patient to take approximately 10 breaths/hour, while awake

c

Constant bubbling in the water seal of a chest drainage system indicates which problem? a) tension pneumothorax b) increased drainage c) air leak d) tidaling

c

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) maintaining continuous bubbling in the water-seal chamber b) keeping the collection chamber at chest level c) measuring and documenting the drainage in the collection chamber d) stripping the chest tube every hour

c

The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? a) smoking particles compete for binding sites on hemoglobin b) smoking decreases the amount of mucus production c) smoking damages the ciliary cleansing mechanism d) smoking causes atrophy of the alveoli

c

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: a) hemoglobin, hematocrit, & RBC levels b) extremities for signs of cyanosis c) oxygen saturation level d) level of consciousness

c

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax? a) paradoxical chest wall movement with respirations b) muffled heart sounds c) diminished or absent breath sounds on the affected side d) sudden loss of consciousness

c

The nurse is caring for a client with tuberculosis. Why should the nurse always encourage a client with tuberculosis to perform active range-of-motion (ROM) exercises three times a day? a) for medication absorption b) for use as a baseline for evaluation c) for maintaining muscle strength d) for effective pain control

c

The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client? a) exhale forcefully while the chest tube is being removed b) while the chest tube is being removed, raise your arms above your head c) when the tube is being removed, take a deep breath, exhale, & bear down d) do not remove during the removal of the chest tube because moving will make it more painful

c

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated. a) I have been coughing all morning & am barely bringing anything up b) I received my pain medication 10 min ago, let's do my CPT now c) I just finished eating my lunch, I'm ready for my CPT now d) I just changed into my running suit; we can do my CPT now

c

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document? a) abnormal bronchial sounds b) normal bronchial sounds c) normal bronchovesicular sounds d) abnormal vesicular sounds

c

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? a) if the test area turns red that means i have tuberculosis b) i will come back in 1 week to have the test read c) because I have had a previous reaction to the test, this time i need to get a chest x-ray d) i will avoid contact with my family until I am done with the test

c

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? a) HPV b) Varicella c) Influenza d) Hep B

c

Which would be least likely to contribute to a case of hospital-acquired pneumonia? a) a highly virulent organism is present b) inoculum of organisms reaches the lower respiratory tract & overwhelms the hosts' defenses c) a nurse washes her hands before beginning client care d) host defenses are impaired

c

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply. a) increased RR b) negative sputum culture c) increased expiratory flow rate d) relief of dyspnea e) increased viscosity of lung secretions

c, d

Why would a client with COPD report feeling fatigued? Select all that apply. a) muscle function gradually decreases over time in clients with COPD b) the client is using all expendable energy for ADLs c) the client is using all expendable energy just to breathe d) lung function gradually decreases over time in clients with COPD

c, d

A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) notify the healthcare provider b) immediately reconnect the chest tube to the drainage apparatus c) clamp the chest tube close to the connection site d) place the chest tube in sterile water

d

A nurse provides care for a client receiving oxygen from a non-rebreather mask. Which nursing intervention has the highest priority? a) changing the mask & tubing daily b) posting a 'no smoking' sign over the clients bed c) applying an oil-based lubricant to the client's mouth & nose d) assessing the client's respiratory status, orientation, & skin color

d

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? a) take all prescribed medications b) drink six glasses of water daily c) exercise daily d) receive vaccinations

d

The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? a) chronic chest pain b) signs of oxygen toxicity c) long, thin fingers d) barrel chest

d