Respiratory 1

What is the reason that the nurse performing tracheal sxning on a client applies continuous sxn only during catheter withdrawal?

To prevent dropping of secretions into trachea

What is the nurse's best response when a 62 yo client whose brother was just diagnosed with head and neck cancer asks what he could do to reduce his risk for also developing this cancer?

"Stop smoking and drink alcohol only in moderation"

Which assessment findings will nurse associate with the possibility of lung cancer? (SATA)

-Dyspnea -Persistent cough -Change in voice quality -Use of accessory muscles

When the SpO2 of a client w very dark skin reads 91% which additional assmts will nurse perform to determine the client's gas exchange adequacy? (SATA)

-Examine the color of oral mucosa -Use capnography to assess end-tidal CO2 levels

Which resp changes does nurse expect to find in an 82 yo client who has no indicators of resp disease? (SATA)

-Exhlation is twice as long as inhalation -Decreased force or cough -Increased AP diameter -Softer voice

Which statements made by a client indicate to the nurse the need for additional edu regarding smoking-realated health risks? (SATA)

-I don't worry about lung problems b/c unlike my wife, I don't smoke daily -I don't worru about lung problems b/c no one in my fam has ever had lung cancer -I am trying to get my college-age daughter to vape rather than smoke b/c it is safer than cigs

Which statements indicate to the nurse that a client has a strong addiction to cig smoking. (SATA)

-I smoke a cig when I wake up before I make coffee -I only watch moves on TV rather than at a theater b/c I can smoke at home -Last night I woke up at 2 am and 5 am to smoke 2 cigs each time

Which client descriptions of sputum production alert the nurse to the possibility of a current resp problem? (SATA)

-Is streaked with mucus -Is frothy & pink -Has a foul odor

Which parameters will nurse monitor to ensure that client's gas exchange response to O2 therapy is adequate? (SATA)

-LOC -Resp pattern -Pulse ox -Resp rate

Which changes does the nurse teach adults to be aware of as warning signs of head & neck cancer? (SATA)

-Lump in mouth, neck or throat -Change in fit of dentures -Difficulty swallowing -Numbness in the mouth, lips or face

Which action s are most important for a nurse to take to prevent harm when caring for a client who is receiving oxygen therapy with a NC? (SATA)

-Making sure that the prongs on the NC are properly positioned in the nares -Applying a water-soluble gel to the nares as needed -Checking the client's skin under the cannula & behind the ears

Which assessment findings are most important for the nurse to determine when assessing a client w dyspnea? (SATA)

-Onset of or when the client 1st noticed dyspnea -Conditions that relieve the dyspnea sensation -Whether or not dyspnea interferes w/ ADLs -Whether stridor is present w dyspnea

Which necessary equipment does nurse ensure is kept at bedside of a client with a newly created tracheosotmy? (SATA)

-Oxygen -Resuscitation bags -Oxygen tubing -Sxn equipment -Trach tray with tube and obturator

Which assmt findings on a client who had a bronchoscopy using the local anesthetic benzocaine spray along w/ light sedation are most important to report to the HCP who performed the procedure? (SATA)

-Oxygen sat is 60% and doesn't increase with supp. O2 -Oral mucus mems are cyanotic -Sputum is grossly bloody

Which instruction must nurse provide to an AP prior to feeding a client who is at risk for aspiration? (SATA)

-Position the client in the most upright position possible -Provide adequate time;do not hurry the client -Encourage the client to tuck his or her chin down and move the forehead forward while swallowing -If the client coughs, stop the feeding until they indicate that the airway has been cleared -Allow the client to indicate when they are ready for next bite

Which actions reflect proper techniques for nurse to use when performing deep sxning on a client with a trach or endotrach tube?

-Preoxygenate the client for at least 30 secs before sxning -Instruct the client that they are going to be sxned -Quickly insert the sxn catheter until resistance is met

Which are the nurse's priority actions when caring for a client who has labored, shallow respirations and a RR of 32 w/ a pulse ox reading of 85%? (SATA)

-Start O2 using a NC at rate of 2 L/min -ASsess other indicators of adequate gas exchange -Place client in upright position

Which activities are most important for the nurse to teach a client with a temporary trach to avoid until cleared by the surgeon? (SATA)

-Swimming -Paddleboarding

Which statements about oxygen therapy are true? (SATA)

-The oxygen provided during oxygen therapy is considered a drug -Nurses must know the purposes and expected outcomes for each client prescribed oxygen therapy

Which findings noted during assessment of a client who reports a resp problem will the nurse document as abnormal?

-Use of pursed-lip brething -Intercostal space 2 finger-breadths wide -Rough scratching sounds over the R lower lobe

What is the nurse's best response to a client who says he is afraid to have pulmonary function testing (PFTs) b/c it may reveal that he has lung cancer?

"These tests only determine whether your breathing is normal and cannot diagnose lung cancer"

Wth which members of the interprofessional team will nurse most commonly collab in providing comprehensive care to clients with head & neck cancer and their fams? (SATA)

--Registered dietitian nutritionist -Respiratory therapist -Speech-language pathologist

Which cients could benefit from use of noninvasive positive-pressure ventilation (NPPV)? (SATA)

-22 yo w an acute asthma attack -36 yo with sleep apnea -64 yo with acute exacerbation of COPD -72 yo with cardiogenic pulmonary edema

With which clients who has tracheostomies will nurse reamin extra vigilant for possible tracheal tissue injury? (SATA)

-42 yo taking corticosteroids daily for a chronic inflamm condition -61 yo with chronic alcoholism and malnutrition -78 yo who also has early-stage prostate cancer

With which clients does the nurse anticipate probable placement of a temporary tracheostomy" (SATA)

-45 yo with facial and oral cavity burns -72 yo with an acute airway obstruction caused by epiglottis

Which client condition does the nurse recognize as most likely to cause a L shift of the oxyhemoglobin dissociation curve? (SATA)

-Alkalosis -Reduced blood & tissue lvels of diaphosphoglycerate (DPG)

In what situations will nurse consider oxygen therapy as possibly beneficial for a client? (SATA)

-Anemia -Hypoxia -pneumonia

Which factors does home health nurse identify as safety hazards in home of a client requiring home oxygen therapy? (SATA)

-Candle on the mantelpiece -Pack of cigs on the coffee table -Electric heater with frayed cord in bathroom

What info will nurse explain to family of client who has been prescribed to receive TTO therapy? (SATA)

-Delivers oxygen directly into lungs -Less likely to cause pressure injury to skin

With which interprofessional team members does nurse expect to collaborate in preparing a client and fam for home care with a permanent trach w/o oxygen therapy? (SATA)

-Discharge planner -Registered dietitian nutritionist -Respiratory therapist -Social worker

With which client will nurse expect to find a barrel chest on resp assessment?

55 yo with chronic emphysema

Which client will nurse educate about relevant lifestyle modifications to decrease risk for head and neck cancer?

57 yo man with chronic alcoholism

Which end-tidal carbon dioxide level in a client being monitored with capnography after anesthesia indicates to the nurse a possible early problem affecting gas exchange?

58 mmHg

How will the nurse document the pack-year smoking hx for a client who reports smoking a pack of cigs a day for 10 years, quitting for 4 yrs and then smoking 2 packs a day for the last 25 yrs?

60 years

WHich condition does nurse suspect when noting a client who is receiving 40% oxygen therapy now has new onset of crackles and decreased breath sounds on auscultation?

Absorptive atelectasis

Which deposition of respiratory phsyiologic features is correct?

Any problem with the R lung interferes with gas exchange and perfusion to a greater degree than a problem in the L lung

What is the priority action for the nurse to take 1st to prevent harm for client whose tissue flap over carotid artery after head & neck surgery is spurting bright red blood?

Apply immediate, direct pressure to the site

Which new-onset problem in a client diagnosed with advanced lung cancer indicates to nurse probable metastasis?

Bone pain

What is the priority action to prevent harm for a nurse to take before allowing a client who had a flexibile bronchoscopy 2 hrs ago to drink or eat?

Checking for return of the gag reflex

For which s/es of therapy will nurse prepare a client who is about to begin external beam radiation for lung cancer?

Chest skin redness and peeling

How will the nurse categorize a client's lvel of dyspnea who reports no SOB at rest, fair to mod SOB while dressing & has to stop to catch his breath when going up a flight of stairs?

Class 3

For which activity does nurse teach the client who is receiving oxyen by a transtracheal oxygen (TTO) delivery system to switch to a NC oxygen delivery system?

Cleaning the catheter

With which client prescribed to receive O2 therapy does the nurse suggest using a face tent rather than a NC?

Client w/ facial trauma

Which client assessment findings does the nurse recognize as an immediate gas exchange & perfusion problem?

Cyanosis

Which precaution is most important for the nurse to take to prevent harm when caring for a client who is breathing on his own and has a fenestrated trach tube with a cuff?

Deflating the cuff before capping the tube with the decannulation cap

Which s/es will nurse teach a client with head and neck cancer who is taking the biotherapy cetuximab to expect?

Development of rash and dry peeling skin

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hrs alerts the nurse to the possibility of oxygen toxicity?

Discomfort or pain under sternum

Which priority action does nurse perform to prevent harm for a client receiving oxygen therapy thru a nonrebreather mask"

Ensuring that valves and flaps are patent, functional and not stuck

What is the priority or most relevant med-surg concept for the nurse when performing an assessment of a client's respiratory system?

Gas exchange

Which question will nurse ask 1st when client reports a persistent, nagging cough?

How lonng has your cough been present?

What is the priority action for the nurse to take to prevent harm when caring for a cleint who is receiving oxygen at 5L/min by NC?

Humidify the O2 with sterile water

Which precaution to prevent harm is most important for nurse to teach a client who is newly prescribed to take varenicline?

Immediately report any change in thought process or suicide ideation b/c this drug can alter behavior

What is the nurse's best 1st action when a client's HR changes from 78 to 48 during nasotracheal suctioning?

Immediately stop suctioning

Which action will nurse take to prevent harm from tracheomalacia in a client who has a newly created tracheostomy?

Maintaining the tracheal cuff pressure between 14-20 mmHg

Which action does nurse caring for a client receiving humidified O2 take to prevent harm from potential infection?

Never draining fluid from the water trap back into nebulizer

How will nurse determine whether a postop client has SQ emphysema following creation of tracheostomy?

Palpating for air under the skin

The nurse assessing a client's respiratory status finds fremitus has increased from the assmt performed yesterday. For which possible resp problem will nurse assess further?

Pneumonia

What type of assessment info does nurse expect to gather when asking a client who has a resp problem whether the symptoms are worse at work or at home?

Possible particulate matter exposure

Which care issue will nurse consider to be highest priority to prevent harm when caring for a client after a suppraglottic laryngectomy for head and neck cancer?

Preventing aspiration

Which action will nurse perform to promote comfort for a client with dyspnea from advanced lung cancer?

Providing supplemental oxygen via cannula or mask

What is the nurse's best 1st action when a client who is 4 days postop w a trach suddenly sneezes during trach care and the tube falls out onto the bed linens?

Quickly & gently replace the tube with a clean cannula kept at the bedside

What is the most appropriate action for the nurse to take to prevent accidental decannulation of client's trach tube?

Securing the tube in place using twill ties or commercial fasteners

Which problem has the highest priority for nurse to help wife of a client with late-stage small cell lung cancer to provide symptom management in the home?

Severe pain

Which assessment finding does nurse expect for a client who has had a neck dissection with removal of musc tissue, lymph nodes, and the 11th cranial nerve?

Shoulder drop with limitation of movement

Which factor does nurse teach clients as the most common cause of chronic resp problems and physical limitations?

Smoking cigarettes or chronic exposure to cig smoke

Which client will nurse assess most often for the possibility of a postprocedure PTX?

Thoracentesis

Which action will nurse recommend for client who suffers from chronic xerostomia induced by radiation treatment for head & neck cancer?

Try using a moisturizing mouth spray

Which complication of a trach does the nurse suspect in a client who has difficulty breathing, noisy resps, difficulty inserting a sxn catheter and thick, dry secretions?

Tube obstruction

How will the nurse document the resp assmt findings on auscultation that are heard as squeaky, musical continuous sounds when the client inhales & exhales?

Wheezes

What is the nurse's best response toa client who asks whether he can use a computer in the same room while using oxygen therapy?

Yes, as long as the cord is not frayed and has a 3-pronged plug

Which ABG values from an 86 yo client does the nurse consider to be normal?

ph: 7.35, PaO2: 94, PaCO2: 42