PCN2 EXAM 1

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance?

"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?

"You should switch to wearing your glasses while taking this medication."

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be

155 mEq/L (155 mmol/L)

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6 to 12 months

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone (Azmacort) is a corticosteroid; Salmeterol (Serevent) is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

Which ventilation-perfusion ratio is exhibited by a pulmonary embolus?

A dead space exists when ventilation exceeds perfusion. An example of a dead space is a pulmonary embolus. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or acute respiratory distress syndrome.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse?

Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?

Air does not conduct sound well, but a solid substance such as a tumor, or fluid that increases the density of the lung, as occurs in pneumonia, does. Therefore, an increase in solid tissue of the normally air-filled lung enhances fremitus, and an increase in air in the lung impedes sound. A patient with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe.

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration. Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take?

Assesses fasting blood glucose levels Adverse effects of methylprednisolone (Solu-Medrol) include abnormalities in glucose metabolism. The nurse monitors blood glucose levels. Methylprednisolone also increases the client's appetite and fluid retention, but the client will not decrease caloric or fluid intake as a result of these adverse effects. It is not necessary to aspirate for blood return prior to injecting the medication, because doing so would not support the intravenous line in the vein.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

Which of the following occupy space in the thorax, but do not contribute to ventilation?

Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange. Alveoli are the functional units of the lungs. Lung parenchyma is lung tissue. Mast cells, when activated, release several chemicals called mediators that include histamine, bradykinin, prostaglandins, and leukotrienes.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted?

COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?

Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

A nurse assesses a client with crackles. What medical condition should the nurse suspect?

Crackles are discrete, non-continuous sounds that result from the delayed reopening of collapsed alveoli. Crackles may or may not be cleared by coughing. They reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, heart failure, asthma, bronchiectasis, and pulmonary fibrosis. Crackles are usually heard on inspiration, but they may also be heard on expiration. A client with a pneumothorax will have absent breath sounds.

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis?

Cyanosis Shoulder pain Dyspnea Tachycardia

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.

Diaphragm contracts and elongates the chest cavity.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

Encourage the client's communication attempts by allowing him time to select or write words.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

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?

Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

HSV-1 is transmitted primarily by direct contact with infected secretions. The incubation period is about 2 to 12 days. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?

In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.

Select the nursing diagnosis that would warrant immediate health care provider notification.

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

Ineffective coping related to anxietyAny factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Although the other choices are correct, the most important psychosocial nursing diagnosis for a patient with COPD is ineffective coping related to a high level of anxiety.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?

Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

Muscle weakness, fatigue, and dysrhythmias

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Muscle weakness; bradycardia; nausea; diarrhea; and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations?

Oliguria Tachycardia Tachypnea

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

On the cheeks below the eyes

Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies?

PET is more accurate in detecting malignancies than CT, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thoracoscopy. A gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?

Paradoxical chest movement

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." In carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

The clinical finding of pink, frothy sputum may be an indication of which condition?

Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which term should the nurse document?

Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Crackles are soft, high-pitched sounds. Pleural friction rub is a creaking or grating sound not affected by coughing. Bronchial sounds are relatively high-pitched sounds.

A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. What drug would the nurse know to administer to the client?

Short-acting beta2-adrenergic agonists include albuterol, levalbuterol, and pirbuterol. They are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They are used to relax smooth muscle.

A nurse is responsible for monitoring indicators of potential complications after laryngectomy. Which indicators would be priority concerns?

Somnolence and hypotension Tachycardia and tachypnea Impaired swallowing Persistent high tracheostomy cuff pressure

The classification of Stage III of COPD is defined as

Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Tactile fremitus is assessed through vibrations of sound on the chest wall by palpation. Normally, fremitus is felt most over the large bronchi and least over the distant lung fields. Clients with emphysema exhibit almost no fremitus, because of the rupture of alveoli and the trapping of air. Air does not conduct sound well.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Tense and relax muscles in the lower extremities.

What clinical indication of hyperphosphatemia does the nurse assess in a patient?

Tetany is a symptom of hyperphosphatemia. Bone pain, paresthesia, and seizures are associated with hypophosphatemia.

Which set of arterial blood gas (ABG) results requires further investigation?

The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3- and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3- 22 to 26 mEq/L.

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:

The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

The goal of pursed-lip breathing is to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance.

The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education?

The nurse should instruct the patient to take the leukotriene receptor antagonist at least 1 hour before meals or 2 hours after meals.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?

Type 2 There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract.

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.

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?

When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.

Which fluid should be administered slowly to prevent circulatory overload?

When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 5% dextrose in 0.9% NaCl and 5% dextrose in lactated Ringer's.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?

While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

With meals

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

The volume of air inhaled and exhaled with each breath is termed

tidal volume.

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

Tingling or numbness in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?

A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

A nurse is admitting a client with emphysema. What are presenting findings the nurse should assess?

Chronic cough Dyspnea Wheezing The clinical manifestations for emphysema is grouped with COPD and includes wheezing, sputum production, and dyspnea. Fever and tachypnea are not common findings.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?

Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

High or increased compliance occurs in which disease process?

High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?

In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

Mobilizing secretions is crucial to maintaining a patent airway and maximizing gas exchange in the client with COPD. Measures that help mobilize secretions include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity. Anxiolytics rarely are recommended for the client with COPD because they may cause sedation and subsequent infection from inadequate mobilization of secretions. Because COPD rarely causes pain, pain medication isn't indicated.

A client is being treated in the ED for respiratory distress coupled with bacterial 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?

Antibiotics are administered to treat respiratory tract infections. Chronic bronchitis is inflammation of the bronchi caused by irritants or infection. Hence, smoking cessation and avoiding pollutants are necessary to slow the accelerated decline of the lung tissue. However, the immediate priority in this case is to cure the infection, pneumonia. Corticosteroids and bronchodilators are administered to asthmatic clients when they show symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern?

Compromised gas exchange Decreased airflow Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD

The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?

Crackles are secondary to fluid in the airways or alveoli or to delayed opening of collapsed alveoli. Sibilant wheezes are associated with asthma and bronchospasm. Fine crackles are associated with pulmonary fibrosis.

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?

Explanation: Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.

A priority nursing intervention for a client with hypervolemia involves which of the following?

Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis?

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?

Rhonchi or sonorous wheezes are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis. Rales or crackles are soft, high-pitched sounds. A venous hum is a blood flow humming sound. Bronchovesicular sound is an intermediate pitch with expiration and inspiration.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?

The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client

The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

The patient is hypoxic from suctioning.

A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?

The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

Which hollow tube transports air from the laryngeal pharynx to the bronchi?

The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.

During a health seminar for the prevention of COPD, a nurse advises participants that the number-one risk factor for COPD is:

There are five major risk factors for COPD. The most important is cigarette smoking.

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care?

To combat dehydration To loosen secretions To facilitate expectoration The nurse also assesses the patient's skin turgor for signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions, and to facilitate expectoration.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply.

Albuterol is a bronchodilator. Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?

Atelectasis

What assessment method would the nurse use to determine the areas of the lungs that need draining?

Auscultation

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

A client has asthma. Which of the following medications is a commonly prescribed mast cell stabilizer used for asthma?

Cromolyn sodium and nedocromil are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment. These medications stabilize mast cells. Though also used in the treatment of asthma the following are NOT mast cell stabilizers: Albuterol is a beta2-antagonist. Budesonide is an inhaled corticosteroid. Theophylline is a mild to moderate bronchodilator.

A decrease in arterial blood pressure will result in the release of:

Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?

Deviation from the midline

A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?

During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?

Sitting on the edge of the bed

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or a flame is dangerous near oxygen.

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body.

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching?

Status asthmaticus Respiratory failure Atelectasis

To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations?

Streptococcus pneumonia and Hemophilus influenzae

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

Swimming is not recommended because a client with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

The process of filtration begins at the:

glomerulus.

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

The classification of Stage II of COPD is defined as

moderate COPD

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?

no longer than 10 seconds

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?

A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Blood fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema.

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

Amoxicillin-clavulanic acid (Augmentin) is the antibiotic of choice to treat ABRS. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones such as levofloxacin (Levaquin) or moxifloxacin (Avelox) can be used. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organism

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

With which condition should the nurse expect that a decrease in serum osmolality will occur?

Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.

Which of the following disease processes cause increased compliance?

High or increased compliance occurs if the lungs have lost their elasticity (cannot return to normal state) and the thorax is overdistended, as in emphysema. Low or decreased compliance occurs if the lungs and thorax are "stiff" (difficult to stretch). Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS).

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.

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?

If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse

If the client vomits large amounts of dark blood at frequent intervals, if the pulse rate and temperature rise, or if the client becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the client's bedside. Needle aspiration is a procedure considered for clients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client

Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Headache, blurry vision, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.

The diaphragm contracts during inspiration and pulls the lungs in a downward and forward direction. The abdomen appears to enlarge because the abdominal contents are being compressed by the diaphragm. With inspiration, the diaphragmatic pull elongates the chest cavity, and the external intercostal muscles (located between and along the lower borders of the ribs) contract to raise the ribs, which expands the anteroposterior diameter. The effect of these movements is to decrease the intrapulmonary pressure.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process?

The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by

The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area.

A nurse is caring for a client experiencing laryngeal obstruction. What clinical finding should lead the nurse to anticipate mechanical ventilation for the client?

The nurse anticipates mechanical ventilation if the client is having neck retractions during inspiration. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the base of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction, not laryngeal swelling.

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.

The calcium concentration in the blood is regulated by which mechanism?

The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anasarca is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:

Use of accessory muscles indicates worsening breathing conditions. Assuming the tripod position, a 93% pulse oximetry reading, and a request for the nurse to raise the head of the bed don't indicate that the client's condition is worsening.

Which is the preferred route of administration for potassium?

When the client cannot ingest sufficient potassium by consuming foods that are high in potassium, administering oral potassium is ideal because oral potassium supplements are absorbed well. Administration by IV is done with extreme caution using an infusion pump, with the patient monitored by continuous ECG. To avoid replacing potassium too quickly, potassium is never administered by IV push or intramuscularly. Potassium is not administered subcutaneously.