prepu respiratory

Obtain vital signs. Apply antiembolic stockings. Keep the client oriented.

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

the client with stridor who just received the first dose of an antibiotic

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

have an anti-inflammatory effect.

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? Steroids will:

"Relax your neck and shoulder muscles." "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." "Pucker your lips as if you were going to whistle." "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."

The nurse is instructing a client with chronic obstructive pulmonary disease how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used.

vertigo

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:

hearing loss

A client is receiving streptomycin to treat tuberculosis. What should the nurse evaluate to determine an adverse effect of the drug?

a laryngectomy tube.

A client is scheduled for radical neck surgery and a total laryngectomy. During the preoperative teaching, the nurse should prepare the client for having:

frontal and maxillary sinuses.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the

Elevate the head of the bed 30 to 45 degrees.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

physical and emotional stress

Clients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk?

thoracic skeletal changes

What factor has the potential to lead to chronic respiratory acidosis in older adults?

coiled flat on the bed and secured without putting tension on the tube

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

"This medicine will make your mouth feel dry."

When administering atropine sulfate preoperatively to a client scheduled for lung surgery, what should the nurse tell the client?

confirming client identification with two qualified health professionals

Which performance improvement strategy helps prevent adverse reactions to blood products?

agrees to call the health care provider (HCP) if dyspnea on exertion increases.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan?

influenza pneumonia pertussis

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? Select all that apply.

runs of ventricular tachycardia

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

decreased breath sounds on the affected side

The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client?

Proceed to suction the client's tracheostomy.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

nonrebreather mask

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations?

Attach the ties of the restraints to the bedframe.

A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate?

Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

preparing the client for a chest tube insertion

A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which action is the nurse's most appropriate action?

pneumothorax subcutaneous emphysema tension pneumothorax pulmonary edema

A client is undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply.

pulmonary hypertension

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?

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:

ineffective breathing pattern related to tissue trauma

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?

a tension pneumothorax.

A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:

at a low flow rate

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which way?

Avoid rigorous aerobic exercise.

A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do?

vesicular

A healthy client presents to the clinic for a routine examination. When auscultating the client's lower lung lobes, the nurse should expect to hear which type of breath sound?

the client lying in a lateral position, with the head of bed flat

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

15-mm induration

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

uses the sternocleidomastoid muscles.

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

Bronchial edema and constriction have worsened.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings?

Medicate the client with prescribed morphine.

A nurse is caring for a client following a thoracotomy. A physical assessment reveals the client has incisional pain, a poor cough effort, and scattered rhonchi throughout all lung fields bilaterally. Which action should the nurse take first?

Assess the client for pain and medicate as appropriate.

A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next?

client verbalization of decreased dyspnea

A nurse is caring for a client who had a chest tube inserted 12 hours ago for treatment of a pleural effusion. Which assessment is most important in determining the client's response to the treatment?

endotracheal suctioning

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

a client with a nasogastric tube

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

The client had a liver transplant 2 years ago.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

A surgical face mask is applied before entering the client's room.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene?

Use diaphragmatic breathing.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

"I should try to eat several small meals during the day."

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions?

The system has an air leak.

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

acute adrenocortical insufficiency.

A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience

Remove inner cannula and clean using universal precautions.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention?

Contact the institutional ethics committee for strategies.

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse-manager would take which step to meet the needs of the staff?

pedal edema

The nurse is assessing a client who has a chronic obstructive respiratory disorder. Which finding should be immediately reported to the healthcare provider?

Supplement the diet with pyridoxine (vitamin B6).

A client with tuberculosis is taking isoniazid (INH). What should the nurse instruct the client to do to help prevent development of peripheral neuropathies?

The oxygen tubing is pinched.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

The heart rate increased 20 beats/minute.

A client with an endotracheal tube is being weaned from the ventilator. For which reason should the procedure be terminated?

10 to 20 mcg/ml

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

Breathe humidified air.

A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which action would help liquefy these viscous secretions?

Administer bronchodilators as prescribed.

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

an inspiratory-expiratory (I:E) ratio of 1:3

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate?

Open the airway. Start an IV access site. Call the health care provider (HCP). Explain the situation to the family.

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used.

antibiotic

A 6-year-old child is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report?

monitor intake and output

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important?

monitoring intake and output

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important?

Further assess the client for reinflation of the lung.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?

respiratory alkalosis.

A client has just been diagnosed as being in status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of:

Do not document in the nursing notes about an incident report being completed. Notify the nursing supervisor and or medical director. Prepare for remediation on medication administration

A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? Select all that apply.

Impaired gas exchange

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

encourage coughing and deep breathing.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must

respiratory depression

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?

age

An older adult client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia?

respiratory acidosis

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

hypoxia not responsive to oxygen therapy

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

auscultating the lungs for bilateral breath sounds

For a client with an endotracheal (ET) tube, which nursing action is the most important?

teaching the client about the disease and its treatment

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?

less difficulty breathing

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?

assess breath souns

The nurse has assisted the health care provider at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. What should the nurse do next?

A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?

increased fremitus

The nurse is auscultating the lungs of a client with bacterial pneumonia. Which finding is expected?

pmeumonia

The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?

auscultation

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

skin test doesn't differentiate between active and dormant tuberculosis infection.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the

increasing the need for antianxiety agents

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care?

nervousness.

A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause

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

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

Make sure the gauze pad is dry and the client is in a comfortable position.

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure). The nursing policy manual recommends use of the gauze pad. What should the nurse do?

The secretions are thinned.

The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. Which indicates the instillation is effective?

pneumonia

The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?

leukocytosis

The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately?

decreased breath sounds

The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the health care provider when the client has which symptom?

"Your alveoli have lost elasticity, which causes retained carbon dioxide."

The nurse is caring for a client with emphysema. The client asks about the reason for persistent respiratory acidosis. What is the best response by the nurse?

"Do not take aspirin-containing medications for 2 weeks before surgery."

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client?

15 sec

When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds?

Use sterile gloves during the procedure.

Which choice demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?

high-calorie, high-protein diet

Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)?

Prepare the client for a chest X-ray.

Which intervention will the nurse expect for a client with a positive tuberculin skin test?