Resp. Prep U

Count the rate of respirations

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform?

Intubate the client and control breathing with mechanical ventilation

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 feeling of swelling at the back of the throat

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

Amoxicillin-clavulanic acid

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

is breathing air in and out of the lungs

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

Oxygen toxicity

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Partial pressure of arterial oxygen (PaO2)

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

nasal cannula at 2 L/minute

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Continues assessing the client's respiratory status frequently

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Expect coughing when using the spirometer properly

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

Partial pressure of arterial oxygen (PaO2)

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

Kinking of the ventilator tubing

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

- 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 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? Select all that apply.

asbestos

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

84 mm Hg

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?

Albuterol

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed?

implementing measures to clear pulmonary secretion

A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes

implementing measures to clear pulmonary secretions

A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes

drink at least 2 L of fluid daily

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:

Manual resuscitation bag

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?

emphysema

A disease of the airways characterized by destruction of the walls of overdistended alveoli

Decreased oxygen requirements

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?

Auscultate the lung for adventitious sounds

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?

Respiratory rate of 22 breaths/minute

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Ventilation exceeds perfusion

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?

Seek medical help if he experiences inability to swallow

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

A positive reaction indicates that the client has been exposed to the disease.

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

Type 2

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

"I should become involved in a weight loss program."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

nasogastric tube pt

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

Do not eat or drink for 6 hours before the procedure

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

"You must consume a diet rich in protein, such as chicken, fish, and beans."

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?

Place the chest tube in sterile water

A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?

On the cheeks below the eyes

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

Hoarseness over 2 wks

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

Absent distal pulses

A nurse working in the radiology clinic is assisting with a client after an unusual arterial procedure. What assessment should the nurse notify the health care provider about?

Flail chest

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Sputum and a productive cough

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?

Pleurisy

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis?

Kussmaul respirations

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

0 to 4 mm

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?

Dyspnea

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Respiratory acidosis

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure?

Partial laryngectomy

A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?

partial rebreathing mask

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

Applying nasal packing

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?

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

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

Ethmoid

A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?

Fluoroscopy

A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order?

Sharp, stabbing chest pain

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:

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?

Cyanosis

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

permanent tracheal stoma would be needed

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

Significant

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Bleeding

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

Water seal chamber

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?

laryngeal cancer

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

Staphylococcus aureus

Bacterial infection occurs in about 70% of those who have acute rhinosinusitis. The nurse is aware that the least common bacteria is:

take antibiotics for the entire 10 days

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

Measuring and documenting the drainage in the collection chamber

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Auscultating the lungs for bilateral breath sounds

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

Respiratory acidosis

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?

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

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.

- Dysphagia - Dyspnea - Persistent hoarseness

Late symptoms of laryngeal cancer include which of the following. Select all that apply.

Emotional support

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

primary drug resistance

Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as

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

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

nuchal rigidity

Stiffness of the neck or inability to bend the neck is referred to as

Acute respiratory distress syndrome

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?

very severe COPD

The classification of Stage IV of COPD is defined as

Semi fowlers

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

nursing assistant is pouring a glass of water to wet the client's mouth

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?

Total laryngectomy

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

60 mm Hg; 90%

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

Asthma

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?

Circulatory hypoxia

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?

Vitamin B6

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

peripheral vascular disease

The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?

Swallow reflex

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Rapid onset of severe dyspnea

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?

Localized calf tenderness

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

Providing sufficient oxygen to improve oxygenation

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment?

PT remain in each position of the postural drainage for 10-15 min

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Symmetry of the client's chest expansion

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:

Crackles in the lung bases

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Apply an ice pack

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

Develop an alternate method of communication

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

A puncture at the radial artery

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

Pulse ox

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?

Routinely deflating the cuff

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

When the patient has less than 30 mL for 2 consecutive days

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

Pneumonia

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?

6 to 12 months

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?

Iodine allergy

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

take the med an hour before meals or 2 hours after a meal

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?

Hoarseness for 2 weeks

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

"I just finished eating my lunch, I'm ready for my CPT now."

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.

Avoid sports activities for 6 weeks

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

Emphysema

The nurse knows that what condition is associated with increased compliance of the lungs?

Atelectasis

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as

Tension pneumothorax

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

tidal volume

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

- Compromised gas exchange - Decreased airflow - Wheezes

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

Auscultation

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

Clubbing of the fingers

What finding by the nurse may indicate that the client has chronic hypoxia?

Mast cells

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

Producing sound

What is the primary function of the larynx?

Orthopnea

When assessing a client, which adaptation indicates the presence of respiratory distress?

no longer than 10 seconds

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

Barrel-shaped chest

Which assessment finding would be most consistent with advanced emphysema?

Pulmonary function studies

Which diagnostic test is the most accurate in assessing acute airway obstruction?

Exposure to tobacco smoke

Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)?

Aspiration pneumonia

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

Ineffective airway clearance

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

impaired verbal communication

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?

Volume cycled

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

See if there are leaks in the system

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

Encourage increased fluid intake

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage deep breathing every 2 hours

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?