Respiratory

a client with tuberculosis asks the nurse about the communicability of the disease. which response would the nurse use?

"untreated active tuberculosis is communicable."

How would the nurse document client findings of abnormal respirations with alternating periods of apnea and rapid breathing?

Cheyne-Stokes respirations

when the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis?

an elevated pH, decreased PCO2

the nurse is providing care to a client who is receiving enteral feedings via a nasograstric (NG) tube. which serious complication would the nurse take measures to prevent?

aspiration pnuemonia

which is the purpose of an occlusive dressing over a client's sucking chest wound?

maintains negative pressure within the chest cavity

when caring for a client in late hypovolemic shock, which complication will the nurse anticipate?

metabolic acidosis (decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis)

which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

mild soap and water

which findings would the nurse expect when doing a respiratory assessment on a healthy young adult?

a midline trachea deep pink nasal mucosa respirations of 14 breaths per minute

which manifestation is an adverse effect of intravenous lorazepam?

amnesia drowsiness sleep driving blurred vision respiratory depression

which clinical manifestations are associated with a diagnosis of tuberculosis?

anorexia hemoptysis night sweats

which clinical findings support the diagnosis of diabetic ketoacidosis (DKA)?

deep respirations and fruity odor to the breath

which pathophysiological abnormality is present in cystic fibrosis

dysfunction of mucus-secreting glands

which symptoms are common during the fulminant stage of inhalation of anthrax?

dyspnea diaphoresis high temperature

which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

encourage coughing and deep breathing

when the nurse auscultates a client's lungs and hears fine, high-pitched, popping sounds in the left lower lung as the client inhales, how would the finding be documented?

inspiratory crackles

which prehospital intervention is the priority for a client bitten by a snake?

moving the victim to a safe area away from the snake and encouraging rest

the nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. which disorder would the nurse consider may be related to these results?

mucobacterium tuberculosis

which is the optimal area for the nurse to assess adequate tissue oxygenation in an African American neonate?

mucous membranes of the mouth

which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube?

palpate around the tube insertion sites for crepitus (when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated)

which team would the nurse consider to be responsible for the treatment of the client rescued from a fire who was found unconscious and having difficulty breathing?

paramedics

after surgery, a client reports sudden, sever chest pain and begins coughing. the nurse suspects the client has a pulmonary embolus based on which characteristic of the client's sputum?

pink

what is a risk factor of necrotizing entercolitis in the preterm infant?

polycthemia

primary nursing action for a client with trauma in the ER?

provide O2 therapy

which lung sound would the nurse expect to hear in a client who experiences laryngeal swelling after extubation?

stridor (a crowing sound usually heard during inspiration that frequently can be heard without a stethescope and indicates upper airway obstruction.

the nurse is providing immediate postop care to a client who has undergone a total laryngectomy. it is appropriate for the plan of care to include which intervention?

suctioning the trach tube whenever necessary (maintains patent airway)

the nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. which is the most important intervention for the nurse to include in this plan?

taking medications as prescribed.

a client taking multiple medications for hypertension develops a persistent, hacking cough. which antihypertensive medication class would the nurse identify as the likely cause of the cough?

angiotensin-converting enzyme (ACE) inhibitors

a client with COPD is admitted to the hospital with a tentative diagnosis of pleuritis. it is important for the nurse to perform which intervention?

assess for signs of pneumonia

nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

atelectasis (occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli)

which disorder would the nurse suspect in the client who has blue nail beds?

cardiopulmonary disease (increase in deoxygenated blood)

which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction?

chest thrusts

which insect or arthropod is the MOST common allergen for children with asthma?

household cockroach

respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks gestation. which would the nurse's assessment of the newborn at this time reveal?

intercostal retractions (a classic sign of RDS in the newborn)

a client is admitted to the hospital with a diagnosis of emphysema. when teaching the client about breathing exercises, the nurse would include which instruction?

perform diaphragmatic exercises to improve contraction of the diaphragm

the nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). which nursing intervention is correct when the client becomes short of breath during the care?

put the client in a high Fowler position

bronchoscopy

the visual examination of the bronchi using a bronchoscope that is inserted in the airways to view and diagnose pulmonary diseases

the parents of an infant with newly diagnosed cystic fibrosis ask the nurse what causes the foul-smelling, frothy stool. which response would the nurse provide?

undigested fat

which finding indicates the presence of hemorrhage in one of these four clients?

client 2: 4.0 million/mm3 (the normal RBC count for a healthy male is 4.7 to 6.1 million/mm3)

for clients experiencing an anaplylactic attack, which medication would the nurse initiate immediately?

isoproterenol (a beta-adrenergic, sympathomimetic medication that is considered to be a first line medication for the management of anaphylaxis. Diphenydramine HCl is a second-line antihistamine and used after the client is stabilized. Hydrocortisone sodium succinate and methylprednisolone sodium succinate are second-line corticosteroid medications that inhibit inflammatory mediators).

A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma?

intrinsic (intrinsic asthma is triggered by an internal factor such as a cold)

which action will the nurse take to support safe oral intake after tracheostomy?

position the client as upright as possible

which complication of cystic fibrosis is related to frequent stools and tenacious mucus?

rectal prolapse(the wasting of perirectal supporting tissues because of malnutrition)

after the nurse has finished teaching a postop client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective?

"I will avoid crossing my legs" (to prevent the constriction of blood flow in the lower leg, which can lead to deep vein thrombosis (DVT))

in which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection?

Semi-Fowler

when assessing a client with emphysema, which finding would the nurse expect?

chest with an increased anteroposterior (AP) diameter

when a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

decreased sounds (because the lung is collapsed)

while assessing the client's skin, the nurse notices a skin condition. the nurse realizes the pathophysiology involve increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. which skin condition is associated with this client?

erythema

which medication would the nurse instruct a client to avoid while taking alprazolam?

opioids, alcohol, barbiturates

the nurse repositions a client who is diagnosed with emphysema to facilitate breathing. which position facilitates maximum air exchange?

orthopneic (a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume)

which is the rationale for palpation of the trachea after a client has had a pneumonectomy?

examining for any mediastinal shift (after pneumonectomy the mediastinum may shift toward the affected side because of the absence of lung tissue on that side after surgery)

what would be the respiratory rate in a 2-year-old child?

30 breaths/min

kussmaul's respiration

Respirations are abnormally deep, regular, and increased in rate.

the nurse is caring for a 75-year-old client who had radical head and neck surgery. thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. which action would the nurse take?

administer the prescribed oxygen

the client admitted to the emergency department after an earthquake in the city with which level of resource intensity would the nurse triage into emergency severity index level 1 (ESI-1)?

client B: high resource intensity; staff at bedside continuously

the nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. when a nurse is providing information to the client about crackles, which is appropriate to include?

crackles are located in the smaller air passages. (fine crackles - sometimes called rales- are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema)

a client with type 1 diabetes has dry, hot, flushed skin; a fruity odor to the breath; and is having kussmaul respirations. which complication does the nurse suspect that the client is experiencing?

ketoacidosis (occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations, decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath).

clients who take rifampin should not take medications from which class?

oral contraceptives (it increases metabolism of oral contraceptives, which may result in an unplanned pregnancy)

which intervention is important in the care of a hospitalized toddler with cystic fibrosis?

performing postural drainage (because the mucus glands secrete thick mucoid secretions that accumulate, reducing ciliary action and mucus flow, the nurse would perform postural drainage, which promotes the removal of mucopurulent secretions by means of gravity)

the nurse is caring for a client with a tracheostomy. which action would the nurse implement when performing tracheal suctioning?

preoxygenate the client before suctioning

which is the function of the water-seal chamber on a closed chest drainage system for a client with hemothorax?

prevents reflux of air back into the pleural space

a client is admitted to the emergency department with a stab wound of the chest. which is a priority nursing assessment?

quality and depth of respirations (ABC)

a child undergoing medication treatment develops hyperthermia, acidosis, and respiratory depression. the nurse understands which type of medication is responsible for the condition?

salicylates (aspirin and other salicylates may cause hyperthermia, acidosis, and respiratory depression)

a newborn with a diaphragmatic hernia has impaired gas exchange. which would the nurse identify as the cause of the infant's decreased gas exchange?

decreased oxygen intake (impacts the lungs ability to expand and take in air)

before beginning administration of morphine via patient-controlled analgesia (PCA), which assessment would the nurse perform first?

respirations (bc morphine decreases the resp. center function in the brain)

which change in the ABGs would the nurse expect in a client with hyperventilation due to anxiety?

respiratory alkalosis

which nursing care plan is indicated for a child admitted to the hospital with pneumonia?

rest

which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

restraints are a last resort to prevent accidental extubation

when assessing the breath sounds of a client with COPD, the nurse hears moist rumbling sounds that improve after the client coughs. how will the nurse document the lung sounds?

rhonchi (coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated)