Resp Saunders

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action should the nurse do first?

Check the client.

A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse should plan to take which actions? Select all that apply.

Check vital signs. Notify the registered nurse. Begin low-flow oxygen therapy.

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral

The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?

"I should not be contagious after 2 to 3 weeks of medication therapy."

The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube?

"To allow for reexpansion of the lung."

The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?

2 L/min

The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list? Select all that apply.

Avoid hot fluids. Avoid rough foods. Rest for the next 24 hours.

A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected?

Bloody

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing.

The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area? Refer to figure.

A

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client?

Abdominal distention

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

Which diagnostic tests indicate active tuberculosis? Select all that apply.

Chest x-ray Gastric analysis washings Sputum smear and culture

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?

Dyspnea

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse should provide which explanation for these symptoms?

Expected and the client should very gradually increase activity as tolerated

The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply.

Hemoptysis A sensation of a "lump" in the throat Hoarseness lasting more than 3 weeks

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first?

Inspect chest tube connections.

A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care?

Instruct the client to reposition himself.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty?

It could decrease the client's oxygen-based respiratory drive.

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Lateral position

The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply.

Loss of smell Chronic cough Nasal stuffiness

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation.

The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer?

Nonproductive hacking cough

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

Peripheral neuritis

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action?

Place the client in high-Fowler's position.

The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?

Places the stethoscope on the client's gown

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.

Position on the side until fully recovered Encouraging coughing and deep breathing Monitoring pulse oximetry readings frequently Encouraging the use of an incentive spirometer

The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client? Select all that apply.

Protect the stoma from water. Soaps should be avoided near the stoma. Wash the stoma daily using a washcloth. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action should the nurse take?

Reinforce the dressing.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority?

Report the findings.

The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?

Residents of a long-term care facility

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply.

Rest Local heat Analgesics

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?

Shortness of breath

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

Sitting on the side of the bed leaning on an overbed table

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement?

Stop the suctioning procedure.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?

The client breathes out slowly through the mouth.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all that apply.

The client leans over a bedside table. The client should sit on the edge of the bed. A time-out is performed before the procedure. A local anesthetic is administered before the procedure.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination?

The system is functioning as expected.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which?

There is a leak in the system that requires immediate investigation and correction.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

Use a picture or word board.

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L