N618: Saunders Respiratory

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1. "I will lie on the affected side for an hour." 2. "I can expect a chest x-ray exam to be done shortly." 3. "I will let you know at once if I have trouble breathing." 4. "I will notify you if I feel a crackling sensation in my chest."

Answer: 1. "I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10."

Answer: 1. "It hurts more when I breathe in." Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1. A shunt unit exists. 2. Anatomical dead space is present. 3. Physiological dead space is present. 4. Ventilation-perfusion matching is occurring.

Answer: 1. A shunt unit exists. Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1. Absence of dyspnea 2. Increased severity of cough 3. Dull percussion notes over lung tissue 4. Decreased tactile fremitus over lung tissue

Answer: 1. Absence of dyspnea Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

The nurse in the post-anesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? 1. Frequent swallowing 2. Client complaints of discomfort 3. Ecchymosis around the client's eyes 4.Blood on the external nasal dressing

Answer: 1. Frequent swallowing Rationale: The client should be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? 1. It is painless and safe. 2. It causes only mild discomfort at the site. 3. It requires insertion of only a very small catheter. 4. It has an alarm to signal dangerous drops in oxygen saturation levels.

Answer: 1. It is painless and safe. Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1. Just under the left clavicle 2. Midsternum, 1 inch to the left 3. Over the fifth intercostal space 4. Midsternum, 1 inch to the right

Answer: 1. Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle.{The apex of the lungs is on top and the bases are on the bottom, unlike the heart, in which the apex is on the bottom and the base is on top}.All of the other options are incorrect locations for assessing the left apex.

The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? 1. Lobes 2. Alveoli 3. Trachea 4. Main bronchi

Answer: 1. Lobes Rationale: Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1. Pleural pain and fever 2. Decreased respiratory rate 3. Diaphoresis during the day 4. Hyper-resonant breath sounds over the left thorax

Answer: 1. Pleural pain and fever Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

A client is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse should document this finding as which sound? Play Sound 1. Stridor 2. Crackles 3. Rhonchi 4. High-pitched wheezes

Answer: 1. Stridor Rationale: The sound that the nurse hears is stridor. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. The nurse immediately notifies the health care provider (HCP). The nurse also places the client in a high Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy. Rhonchi (low-pitched, coarse, loud, low snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. High-pitched wheezes are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema.

The nurse is monitoring the function of a client's chest tube that is attached to a 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? 1. Tidaling is present. 2. There is a leak in the system. 3. The client has residual pneumothorax. 4. Suction should be added to the system.

Answer: 1. Tidaling is present. Rationale: 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. Options 2, 3, and 4 are inaccurate interpretations.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate? 1. "You lack the energy to cook wholesome meals." 2. "Blocked nasal passages impair the sense of smell." 3. "Loss of appetite is triggered by the infectious organism." 4. "Infection blocks sensation in the taste buds of the tongue."

Answer: 2. "Blocked nasal passages impair the sense of smell." Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom.

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching? 1. "I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider."

Answer: 2. "I should remove the chest tube site dressing as soon as I get home." Rationale: When a chest tube is removed, an occlusive dressing, usually consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the health care provider says it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate? 1. "The numbness is normal and is likely to be permanent." 2. "In many cases the nose and upper lip are numb for up to 6 months." 3. "Numbness usually indicates nerve damage that occurred during the procedure." 4."You will need to see the health care provider because this may indicate a complication of the procedure."

Answer: 2. "In many cases the nose and upper lip are numb for up to 6 months." Rationale: The nurse should instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? 1. "It will open up the major airways." 2. "It will keep the small airways open." 3. "It will increase lubrication for the lungs." 4. "The lungs can better rid themselves of secretions."

Answer: 2. "It will keep the small airways open." Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not reasons for sustaining inflation.

The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? 1. 16% 2. 21% 3. 30% 4. 40%

Answer: 2. 21% Rationale: Room air contains 21% oxygen. It is not possible to give a client 16% oxygen because that is less than room air. Options 3 and 4 specify oxygen amounts that commonly are used to supplement clients who are experiencing respiratory difficulty.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

Answer: 2. Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

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 finding, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe.

Answer: 2. Continue to monitor the client. Rationale: 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, a dependent loop exists, the suction is not working properly, or the lung has re-expanded. Because this finding is expected, it is not necessary to notify the HCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? 1. Osmosis 2. Diffusion 3. Ionization 4. Active transport

Answer: 2. Diffusion Rationale: Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

The 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 is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

Answer: 2. Document the findings. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) 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. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider (HCP). 4. Change the chest tube drainage system.

Answer: 2. Document the findings. Rationale: Bubbling in the water seal compartment 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. Therefore, it is unnecessary to call the HCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicates an air leak. If this occurs, it must be corrected.

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system? 1. Empty the drainage collection chamber every shift. 2. Ensure the water level in the water seal chamber is at the 2-cm level. 3. Maintain the drainage collection device at the level of the client's chest. 4. Clamp the chest tube before moving the client from the bed to the chair.

Answer: 2. Ensure the water level in the water seal chamber is at the 2-cm level. Rationale: The water seal chamber acts as a 1-way valve. It allows air and fluid to leave the pleural space but prevents reentry of atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. A chest tube should not be clamped unless specifically prescribed.

The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse should document this finding as which sound? Play Sound 1. Crackles 2. High-pitched wheezes 3. Bronchial breath sounds 4. Bronchovesicular breath sounds

Answer: 2. High-pitched wheezes Rationale: The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? 1. Increase to 3 L/min and titrate until the SpO2 is 95%. 2. Increase to 3 L/min and titrate until the SpO2 is 88%. 3. Place the client on a nonrebreather mask on 100% FiO2. 4. Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

Answer: 2. Increase to 3 L/min and titrate until the SpO2 is 88%. Rationale: Oxygen is used cautiously and should be titrated to the lowest amount needed; however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and the current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%.An SpO2 of 95% is the recommended level for a healthy individual{with no COPD};therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect.

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1. Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal, expected finding.

Answer: 2. Notify the health care provider (HCP). Rationale: Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. {Other options that if present will be correct include: A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty & subcutaneous emphysema. The nurse should check for an air leak. First, check to see if someone has increased the suction rate; if it is not on high, then check to see if the problem is with the pt or the system (leak)}. The remaining options are incorrect.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape

Answer: 2. Petrolatum gauze and sterile 4 × 4 gauze Rationale: On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the HCP as the tape of choice to make the dressing occlusive

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4.The occlusive dressing at the insertion site needs reinforcement.

Answer: 2. The chest tube is functioning as expected. Rationale: 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 the suction is not working properly, or if the lung has reexpanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water seal chamber.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.

Answer: 2. The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1. The drainage is serous. 2. The drainage is bloody. 3. The drainage is serosanguineous. 4. The drainage is bloody, with frequent small clots.

Answer: 2. The drainage is bloody. Rationale: In the first few hours after surgery the drainage from the chest tube is bloody. After several hours it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1. Air flows by gravity. 2. The respiratory muscles relax. 3. The respiratory muscles contract. 4. Air is flowing against a pressure gradient.

Answer: 2. The respiratory muscles relax. Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1. Sitting position 2. Tripod position 3. Supine position 4. High Fowler's position

Answer: 2. Tripod position Rationale: The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

Answer: 2. Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

Answer: 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L Rationale: A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction? 1. "I should sleep on 2 pillows to elevate my head." 2. "I should avoid any activities such as bending over." 3. "I should be sure to run a dehumidifier in my home." 4."I need to sneeze through the mouth and not blow through the nose."

Answer: 3. "I should be sure to run a dehumidifier in my home." Rationale: After rhinoplasty, the client is taught to sleep on at least 2 pillows; this elevates the head and reduces edema. The client also is told to avoid any activities, such as bending over, that would increase intracranial pressure and cause nasal bleeding. A humidifier (not a dehumidifier) decreases the dry throat associated with mouth breathing. The client should be instructed to sneeze through the mouth and not blow through the nose.

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? 1. "Strapping is useful only if the ribs are fractured in several places at once." 2. "That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." 3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4. "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

Answer: 3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." Rationale: 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. Therefore, options 1, 2, and 4 are incorrect.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? 1. Do not exceed 1 L/min. 2. Do not exceed 2 L/min. 3. Adjust the oxygen depending on SpO2. 4. Adjust the oxygen depending on respiratory rate.

Answer: 3. Adjust the oxygen depending on SpO2. Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. All other options are incorrect.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? 1. Instruct the client to limit fluid intake. 2. Place the client in low Fowler's position. 3. Administer the prescribed bronchodilator. 4. Place a continuous pulse oximeter on the client.

Answer: 3. Administer the prescribed bronchodilator. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing. {In distress, don't assess, option 4 is assessment. We know the pt has SOB and decreased breath sounds, so, we need intervention rather than assessment}.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? 1. Place the client in supine position. 2. Apply an ice collar around the client's neck. 3. Assist the client to a sitting position with the head tilted forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled.

Answer: 3. Assist the client to a sitting position with the head tilted forward. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

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? 1. Dry cough 2. Hematuria 3. Bronchospasm 4.Blood-streaked sputum

Answer: 3. Bronchospasm Rationale: 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 of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? 1. Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

Answer: 3. Document the findings. Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction? 1. Drink water while chewing the gum. 2. Only chew the gum for a maximum of 10 minutes. 3. Hold the gum between the cheek and teeth periodically. 4. Eat a light snack immediately before chewing the gum.

Answer: 3. Hold the gum between the cheek and teeth periodically. Rationale: Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink should be avoided 15 minutes before or during use.

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? 1. Prevents the client from getting a nosebleed 2. Gives the client added fluid via the respiratory tree 3. Humidifies the oxygen that is bypassing the client's nose 4. Prevents fluid loss from the lungs during mouth breathing

Answer: 3. Humidifies the oxygen that is bypassing the client's nose Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. A client who is breathing through the mouth is not at risk for nosebleeds. The humidified oxygen may help keep mucous membranes moist, but it will not substantially alter fluid balance (options 2 and 4).

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? 1. Increased oxygen saturation with ambulation 2. A widened diaphragm documented by chest x-ray 3. Hyperinflation of lungs documented by chest x-ray 4. A shortened expiratory phase of the respiratory cycle

Answer: 3. Hyperinflation of lungs documented by chest x-ray Rationale: The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1. Position the client in semi Fowler's position. 2. Add water to the suction chamber as it evaporates. 3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system.

Answer: 3. Instruct the client to avoid coughing and deep breathing. Rationale: 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 reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Lying on the back in a low Fowler's position 4. Sitting up with the elbows resting on the knees

Answer: 3. Lying on the back in a low Fowler's position Rationale: The client should not lie on the back because this reduces movement of a large area of the client's chest wall. The client should use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1. Dilate the major bronchi. 2. Increase surfactant production. 3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree.

Answer: 3. Maintain inflation of the alveoli. Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1. Aids in exhalation 2. Moves up and inward 3. Moves downward and out 4. Makes the thoracic cage smaller

Answer: 3. Moves downward and out Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? 1. Aids in exhalation as it contracts 2. Moves up and inward as it contracts 3. Moves downward and out as it contracts 4. Makes the thoracic cage smaller as it contracts

Answer: 3. Moves downward and out as it contracts Rationale: As the diaphragm contracts it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, the remaining options are incorrect.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

Answer: 3. Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? 1. Alveoli 2. Trachea 3. Pleural space 4. Main bronchi

Answer: 3. Pleural space Rationale: Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1. Initiate and maintain supplemental oxygen as prescribed. 2. Plan activities with rest periods to conserve oxygen needs. 3. Provide nasotracheal suctioning as needed to remove secretions. 4. Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

Answer: 3. Provide nasotracheal suctioning as needed to remove secretions. Rationale: Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is in the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance.

The nurse is caring for a client who has just returned from the post-anesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period? 1. Serous 2. Grossly bloody 3. Serosanguineous 4. Serous with sputum

Answer: 3. Serosanguineous Rationale: Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The remaining options are not expected findings.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? 1. "I need to avoid alcohol and sedative medications." 2. "I have to cut down on the percentage of carbohydrates in my diet." 3. "Besides smoking, I can't be around second- or thirdhand smoke." 4. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

Answer: 4. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." Rationale: Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? 1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

Answer: 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Rationale: Clients should be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.

The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1. Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal chamber during inspiration and expiration.

Answer: 4. Continuous bubbling is observed in the water seal chamber during inspiration and expiration. Rationale: Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of reexpansion of the lung or obstruction or kinking of the chest tube.

The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action? 1. Ensure that suction is turned on. 2. Reinforce the occlusive dressing. 3. Encourage the client to breathe deeply. 4. Document the accurate functioning of the tube.

Answer: 4. Document the accurate functioning of the tube. Rationale: 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, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. There is no need to ask the client to breathe deeply or reinforce the dressing. The suction should be turned on if prescribed, but there are no data in the question to indicate this HCP prescription.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? 1. Low cardiac output secondary to cor pulmonale 2. Gas exchange alteration related to ventilation-perfusion mismatch 3. Altered breathing pattern secondary to increased work of breathing 4. Inability to clear the airway related to inability to expectorate sputum

Answer: 4. Inability to clear the airway related to inability to expectorate sputum Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? Stop Sound 1. Obstruction of the bronchus 2. Inflammation of the pleural surfaces 3. Passage of air through a narrowed airway 4. Opening of small airways that contain fluid

Answer: 4. Opening of small airways that contain fluid Rationale: The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched, discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial, low-pitched, coarse rubbing or grating sound) is heard when the pleural surfaces are inflamed. Passage of air through a narrowed airway is associated with wheezes (a high-pitched musical sound similar to a squeak).

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

Answer: 4. Pain, especially with inspiration Rationale: Rib fractures result from a blunt injury or a fall. 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.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? 1. Continue to monitor. 2. Document the findings. 3. Change the chest tube drainage system. 4. Perform a focused respiratory assessment.

Answer: 4. Perform a focused respiratory assessment. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) 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. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system are not indicated at this time. Continuing to monitor delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1. Focus only on the physical examination. 2. Obtain all information from family members. 3. Use the health care provider's medical history. 4. Plan short sessions with the client to obtain data.

Answer: 4. Plan short sessions with the client to obtain data. Rationale: The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information.Option 3 is incorrect because the health care provider's medical history provides data that are different from the nurse's assessment. All efforts should be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.

Answer: 4. Promote carbon dioxide elimination. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min 4. Respiratory rate of 22 breaths/min

Answer: 4. Respiratory rate of 22 breaths/min Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting up and leaning on an overbed table

Answer: 4. Sitting up and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? 1. Take a deep breath. 2. Exhale immediately. 3. Breathe in and out quickly. 4. Take a deep breath and hold it.

Answer: 4. Take a deep breath and hold it. Rationale: When the chest tube is removed, the client is asked to take a deep breath and hold it. The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seal themselves off, and the wound heals in less than 1 week.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tube may be obstructed.

Answer: 4. The chest tube may be obstructed. Rationale: Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? 1. The client will lose consciousness. 2. The client's sodium and chloride levels will rise. 3. The client will complain of facial numbness and tingling. 4. The client's arterial blood gas results will reflect acidosis.

Answer: 4. The client's arterial blood gas results will reflect acidosis. Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

Answer: 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding? 1. The drainage chamber is full. 2. The pneumothorax is resolving. 3. The suction chamber system is shut off. 4. There is an air leak somewhere in the system.

Answer: 4. There is an air leak somewhere in the system. Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4.Clamp the chest tube and notify the health care provider immediately.

Answer: 2 Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

Answer: 2 Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply. 1. Anosmia 2. Chronic cough 3. Purulent nasal discharge 4. Intolerance to hot weather 5. Intolerance to strong aromas

Answers: 1. Anosmia 2. Chronic cough 3. Purulent nasal discharge Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and strong aromas are not characteristics.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. 1. Dry air 2. Clean air 3. Exercise 4. Rest and sleep 5. An upper respiratory infection (URI) 6. Nonsteroidal antiinflammatory drugs (NSAIDs)

Answers: 1. Dry air 3. Exercise 5. An upper respiratory infection (URI) 6. Nonsteroidal antiinflammatory drugs (NSAIDs) Rationale: Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. 1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 4. Decreased respiratory rate 5. Increased body temperature 6. Prolonged expiratory breathing phase

Answers: 1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 6. Prolonged expiratory breathing phase Rationale: The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. 1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 4. Get a flu shot immediately. 5. Eat fruits and vegetables high in vitamin C.

Answers: 1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 5. Eat fruits and vegetables high in vitamin C. Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. 1. Sit upright in the bed or in a chair. 2. Inhale as deeply and quickly as possible. 3. Hold the device in a downward position. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

Answers: 1. Sit upright in the bed or in a chair. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Rationale: For optimal lung expansion with an incentive spirometer, the client should assume a semi Fowler's or high Fowler's position while holding the incentive spirometer in an upright position. The mouthpiece should be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Lying supine with the feet elevated 4. Sitting up with the elbows resting on knees 5. Lying on the back in a low Fowler's position

Answers: 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 4. Sitting up with the elbows resting on knees Rationale: The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply. 1. The dry suction control regulation set to the prescribed amount 2. The water filled suction control chamber filled to the prescribed amount 3. Increased intermittent bubbling in the water seal chamber when the system is to gravity 4. Continuous bubbling in the water seal chamber when the system is connected to suction 5. The drainage in the collection chamber marked each shift to monitor the amount of drainage

Answers: 1. The dry suction control regulation set to the prescribed amount 5. The drainage in the collection chamber marked each shift to monitor the amount of drainage Rationale: There are 2 types of chest drainage systems: the wet drainage system and the dry drainage system. On routine assessment of the system, the nurse should look at the different chambers. For a dry drainage system, the nurse should check the dry suction control regulation and make sure it is set to the prescribed amount. The nurse should also look for the orange floater ball to appear in the window; this indicates that the suction is being applied correctly. Tidaling should be noted in the water seal chamber. The nurse should also check the water seal chamber; if the system is connected to suction (as opposed to gravity), tidaling may not be seen and the suction should be turned off to check for tidaling. If continuous bubbling is noted or the bubbling increases, an air leak may be present and the connections should be checked. In a dry drainage system, water is not added to the suction control chamber; this is done with a wet drainage system. The drainage collection chamber should be monitored and marked each shift to monitor the amount of drainage, if any.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. 1. Purified air 2. Cigarette smoking 3. Genetic risk factor 4. Environmental factors 5. Eating plenty of fruits and vegetables 6. Alpha-1 antitrypsin (AAT) deficiency

Answers: 2. Cigarette smoking 3. Genetic risk factor 4. Environmental factors 6. Alpha-1 antitrypsin (AAT) deficiency Rationale: Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

Which are possible causes of upper airway obstruction? Select all that apply. 1. Thin secretions 2. Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement

Answers: 2. Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1. Reduce fluid intake to less than 1500 mL/day. 2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. 5. Keep the client in a supine position as much as possible.

Answers: 2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1. A low arterial PCo2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

Answers: 2,3 Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

Answers: 3,4,5,6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

Answers: 4 Rationale: 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. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.