respiratory- archer

The nurse is performing a respiratory assessment of a client with abnormal breathing patterns. The client has periods of apnea with periods of gradually increasing and decreasing breaths. How should the nurse chart this breathing style?

Cheyne-Stokes Cheyne-Stokes respiration is characterized by apnea alternating with periods of rapid breathing. This pattern is often seen in various medical conditions, including heart failure and brain injuries.

The nurse is teaching the parents of a client with cystic fibrosis. Which statement, if made by the parents, would require follow-up?

"Chest physiotherapy should be done before giving bronchodilators." This statement requires follow-up. Bronchodilators should be administered before chest physiotherapy to enhance the mobilization of secretions, allowing them to be expelled.

The nurse is educating a client scheduled for pulmonary function tests. It would indicate effective teaching if the client makes which statement?

"I should not use my bronchodilator four to six hours before these tests." Bronchodilators, such as inhalers, can impact the results of pulmonary function tests. It is generally recommended to withhold the use of a bronchodilator for a specific period before the tests to obtain accurate results. This period may vary depending on the specific medication and the healthcare provider's instructions, but the client's statement about withholding the bronchodilator for four to six hours before the tests is generally appropriate.

The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching?

"I should record the highest of the three readings." The child's highest reading out of three times should be recorded (not the average). It is important that between each measurement, a 30-second rest is taken by the child.

The nurse has provided education to a client diagnosed with obstructive sleep apnea (OSA). Which client statement would indicate a correct understanding of the teaching?

"I will plan on exercising at least 150 minutes a week." A crucial part of mitigating the symptoms of obstructive sleep apnea is for a client to lose weight. Weight reduction is a pivotal part of the treatment plan for an individual with OSA, as being overweight or obese causes fat deposits in the upper airways. Reducing these fat deposits improves muscle activity and allows for better ventilation. The client stated that they plan on exercising 150 minutes a week is a favorable response because that is the national recommendation ✓ During sleep, head and neck muscles relax, displacing the tongue, soft palate, and neck structures, thus causing obstruction. ✓ Manifestations of OSA include the client snoring, waking up not rested, irritability, and a headache in the morning ✓ OSA is a concern because it raises blood pressure which may increase the client's risk for hypertension, stroke, and myocardial infarction ✓ Diagnosis is through a validated questionnaire or sleep study ✓ Treatment is weight reduction, instructing the client to avoid alcohol before bed, certain oral appliances, positive pressure ventilation, and consultation with an ear, nose, and throat specialist to determine if any surgical intervention may be helpful ✓ For the client receiving CPAP, the nurse should instruct the client to keep the device sanitized as it may be a source of pneumonia

The nurse is working with an advocacy group to raise awareness about cystic fibrosis. Which statement best explains the condition?

"It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages." ✓ Cystic fibrosis is not limited to the United States; it is a global health concern. According to the World Health Organization (WHO), cystic fibrosis occurs in people of all ethnic backgrounds, with higher prevalence reported in populations of European descent. ✓ Regular monitoring of respiratory function, nutritional status, and overall health is essential. Nurses collaborate with the healthcare team to assess and address changes in the client's condition promptly. ✓ Living with a chronic condition like cystic fibrosis can be challenging. Nurses provide psychosocial support by addressing emotional needs, facilitating support groups, and connecting clients and families with resources for coping and mental health support.

A nurse has attended a continuing education conference about seasonal influenza. Which of the following statements would indicate a correct understanding of the conference?

"The live attenuated vaccine (LAV) is for healthy non-pregnant individuals, starting from 2 years of age up to 49" This statement is correct. The LAIV is a nasal spray flu vaccine approved for use in healthy non-pregnant people, 2 through 49 years old. Individuals who are pregnant, immunocompromised, younger than 2, or older than 49 should not receive this vaccine. The LAIV contains weakened influenza viruses that are cold-adapted, which means they are designed to only multiply at the cooler temperatures found within the nose and not the lungs or other areas where warmer temperatures exist. No influenza vaccine causes influenza. The LAIV has demonstrated a more robust immune response when compared to the IIV.

The nurse is providing asthma education to a teen that has just been diagnosed with asthma. Which of the following statements by the client would indicate a need for further teaching?

"When I am having an asthma attack, I should call 911 first." - For most clients, the first step is to take short-acting inhaler medications. It is not necessary to first call 911 for every asthma attack as symptoms often improve with less aggressive interventions. "I've really been wanting to get a dog and my asthma will not stop me." "I should inhale quickly when using my albuterol inhaler." - This statement indicates a need for further education. When administering albuterol via an inhaler, the client should not take a quick or shallow breath. Instead, when delivering the dose, the client should be taught to inhale slowly and deeply to help the medication reach the small airways in the lungs. "I will take theophylline prior to exercising." - This statement indicates a need for further education. Theophylline is a bronchodilator that works as a long-term medication for asthma. This medication must be taken regularly to be effective and does not work immediately so would not be useful if only taken prior to exercising.

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include?

"You will need to report any shortness of breath following the procedure." "After the procedure, a follow-up chest x-ray will be done." These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/symptoms were to occur. A chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 hours. It has been reported <1% in most studies are associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from cough and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics.

Use of a Peak Expiratory Flow Meter

1. Before each use, make certain the sliding marker or arrow on the peak expiratory flow meter is at the bottom of the numbered scale. 2. Stand up straight. 3. Remove gum or food from your mouth. 4. Close your lips tightly around the mouthpiece. Be certain to keep your tongue away from the mouthpiece. 5. Blow out as hard and as quickly as you can, a "fast, hard puff." 6. Note the number by the marker on the numbered scale. 7. Repeat entire routine three times, but wait at least 30 seconds between each routine. 8. Record the highest of the three readings, not the average. 9. Measure your peak expiratory flow rate (PEFR) close to the same time and same way each day (e.g., morning and evening; before and 15 minutes after taking medication). 10. Keep a record of your PEFRs. ✓ Emphasize the importance of regularly monitoring peak flow as part of the child's asthma management plan. This helps track changes in lung function and enables timely intervention. ✓ Reinforce the importance of medication adherence as prescribed by the healthcare provider. Proper use of controller and rescue medications is crucial for maintaining asthma control.

interventions to prevent atelectasis

1. Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry (Choice E). An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. 2. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. 3. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion. The above interventions are aimed at preventing atelectasis. However, the nurse should be aware of detecting atelectasis if it did end up happening. Physical exam findings assist in the diagnosis and include fever and decreased breath sounds on the side of atelectasis. In the case of complete atelectasis/collapse, the trachea/mediastinum may be shifted to the same side due to the pull by a collapsed lung. Atelectasis in the postoperative period is referred to as "resorption atelectasis" but the nurse should also be aware of other types in different client scenarios.

The nurse is preparing to suction a client's tracheostomy. Place the steps in the appropriate order that the nurse should perform. Place the steps below in the appropriate order.

1. Identify the client, perform hand hygiene, and gather supplies 2. Apply a continuous pulse oximeter to the client 3. Perform hand hygiene and apply personal protective equipment (PPE) 4. Using an aseptic technique, open the suction kit or catheter package and prepare supplies 5. Apply sterile gloves 6. Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent 7. Suction the client as the catheter is removed for a maximum of 15 seconds.

Once the nurse detects atelectasis, treatment interventions from a nurse's perspective include

1. Use of incentive spirometry (IS) - IS mimics the natural process of sighing or yawning. It encourages the patient to take slow and deep breaths. The result of this process is decreased pleural pressure, increased lung expansion, and improved gas exchange. Regular repetition of IS can prevent or even reverse atelectasis. 2. Supportive devices to assist with deep coughing. 3. Chest physiotherapy includes tapping on the chest to loosen mucus 4. Mobilizing the patient early, i.e. encouraging sitting up in bed, sitting over the edge of the bed, standing, or assisted ambulation. 5. Postural drainage - to achieve this, the body is positioned with the head lower than the chest to promote gravitational drainage of the mucus from the bottom of the lungs. (Note this position is for treatment of atelectasis and is different from the semi-recumbent area used to prevent atelectasis) 6. Bronchoscopy may be ordered in certain cases by the physician to remove the mucus plug if the patient is not showing improvement despite the above non-invasive measures.

The client is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the client's risk of developing a respiratory infection?

Assist the client to turn and reposition frequently Place the client in a semi-fowlers position Encourage deep breathing and coughing. Respiratory infections are common in acute pancreatitis due to retroperitoneal fluid pushing the diaphragm upwards and causing the client to take shallow abdominal breaths. Assisting the client to change positions frequently, encouraging deep breathing, coughing exercises, and positioning clients for maximum chest expansion would all be preventative interventions to reduce the risk of respiratory infection.

A 70-year-old client was admitted for pneumonia. The client developed acute respiratory distress syndrome resulting in respiratory arrest, requiring an endotracheal tube. Attempts to wean the client from mechanical ventilation were ineffective, and the client received a tracheostomy. How can the nurse minimize bleeding around the insertion site for the first 24 hours following tracheostomy?

Avoid manipulating the tracheostomy, and do not deflate the cuff In the absence of an emergency, the cuff should never be deflated during the initial 24-hour period. In order to minimize the risk of bleeding around the insertion site for the initial 24 hours following a tracheostomy, the nurse must minimize the number of tracheostomy manipulations that occur. Each time a tracheostomy tube is manipulated, there is an opportunity for complications and associated morbidity. Every manipulation carries the risk of trauma to the tracheostomy wound and accidental decannulation.

The nurse has just finished assisting the surgeon with inserting a chest tube in a client with a pneumothorax. Which assessment finding indicates that the procedure has produced its desired effect?

Clear breath sounds are auscultated bilaterally Bilateral breath sounds indicate that both the clients' lungs have expanded, which is the procedure's objective. A pneumothorax produces diminished or absent breath sounds in the affected lung. Once the chest tube has exerted its desired effect, the lung sounds should become clear.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder?

Check the amount of oxygen in the cylinder before using it.

The nurse is caring for a client with lung cancer who recently had a left lower lobe removal. Which postoperative intervention will be performed as a priority in the care of this client?

Closed chest drainage system A closed chest drainage system is the priority postoperative intervention for a client who has had a left lower lobe removal. This system is used to manage the drainage of air or fluid from the pleural space, which is crucial in preventing complications such as pneumothorax or pleural effusion. ✓ Ensuring the proper functioning of the chest drainage system immediately after surgery is essential to prevent complications directly related to the surgical procedure and to maintain optimal lung function. ✓ Monitor and manage the client's pain effectively. Pain can hinder deep breathing and coughing, which are essential for lung expansion. Administer prescribed pain medications as needed. ✓ Educate the client about pulmonary hygiene techniques, including the use of an incentive spirometer, coughing, and proper positioning, to prevent respiratory complications.

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children?

Cricoid The cricoid appears as a full circular ring and is the most narrow part of the airway. While intubating, it can be useful to place pressure on the cricoid to make the airway more comfortable to access.

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis restlessness

Epiglottitis, Laryngotracheobronchitis

What findings are expected when assessing a patient with atelectasis?

Decreased breath sounds Decreased tactile fremitus Shortness of breath Decreased oxygen saturation Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and gas exchange by diffusion in the lungs. With atelectasis, lung tissue has collapsed, which leads to less lung mass available for oxygenation. The oxygen saturation is decreased, as well as breath sounds. Additionally, the patient will experience shortness of breath. Since alveoli collapse, there is more open space between the lung tissue and the chest wall. Open space does not transmit sound very well (decreased tactile fremitus). Areas of the lung with atelectasis cannot fulfill the function of respiration. Coughing, chest pain, cyanosis, dyspnea, and tachycardia are common symptoms of atelectasis.

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client?

Deep inspiration. Supine position with the head end of the bed elevated. Change position every 2 hours. Encourage the patient to cough at least 10 times/hr. Encourage use of incentive spirometry

Continuous Positive Airway Pressure (CPAP)

Delivers a constant flow of air at a steady pressure Keeps the airways open during both inhalation and exhalation Beneficial for conditions like sleep apnea

Bilevel Positive Airway Pressure (BiPAP

Delivers two levels of pressure during the respiratory cycle Higher pressure during inhalation, lower pressure during exhalation Assists with the effort of breathing in and releasing air during exhalation Used for respiratory failure and certain types of sleep apnea.

The nurse attends to a client with shortness of breath, bilateral lung crackles, weak pulses, and frothy pink sputum. Which of the following orders should the nurse question for this client?

Diltiazem The client is exhibiting symptoms and signs of left ventricular heart failure. Decreased cardiac output associated with acute systolic heart failure results in reduced blood pressure, weak pulses, and acute pulmonary edema (dyspnea, frothy pink sputum, and lung crackles). Diltiazem and other calcium channel blockers (CCBs) produce a negative inotropic effect (reduced myocardial contractility) and are contraindicated in acute systolic heart failure. CCBs may exacerbate systolic dysfunction and cause heart failure symptoms to worsen. The nurse should question this order to determine if there is a more appropriate medication to accomplish the intended therapeutic effect with a lower risk of complications.

The nurse is caring for a client with a tracheostomy receiving oxygen via tracheostomy collar. The nurse should plan to

Ensure that the oxygen is humidified Suction the tracheostomy for a maximum of three passes When caring for a client with a tracheostomy, suctioning should be performed only when clinically indicated. Indications for suctioning the client include tachypnea, rhonchi in the lung fields, and decreasing oxygen saturation. When suctioning a tracheostomy, the nurse should use a sterile technique, and a maximum of three passes should be completed. The oxygen must be warm and humidified for a client receiving oxygen via a trach collar. If it is not appropriately warmed or humidified, tracheal damage may occur. The humification assists with the passage of the secretions.

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis muffled voice

Epiglottitis

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis tripod position with drooling

Epiglottitis,

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client's respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding?

Finish counting the client's respirations It is appropriate for the nurse to finish counting the client's respirations and continue to monitor them as normal. Fluctuations of water in the water-seal chamber with inspiration and expiration are a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and then decrease when they breathe out. This is due to changes in intrathoracic pressures.

pulmonary edema

Pulmonary edema is a severe condition that causes impaired gas exchange from excessive fluid in the interstitium of the lung. Pulmonary edema may be cardiogenic (caused by heart failure) or noncardiogenic (severe hyponatremia, heat stroke, liver cirrhosis, renal failure). Pulmonary edema causes an individual to experience restlessness, crackles in the lung fields, productive cough, tachypnea, dyspnea, and hypoxia.

For a client being discharged with oxygen therapy, important teaching points to emphasize include

Have a pulse oximetry device readily available. Avoiding any open flame or heat. This includes an oven, stovetop, candles, matches, and cigarettes. Flammable products such as alcohol and oil should be avoided. Have working smoke detectors in the home as well as fire extinguishers. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish any open flames before entry. Use a water-soluble jelly to lubricate the nasal passages and mouth to prevent drying.

For a client being discharged with oxygen therapy, important teaching points to emphasize include:

Have a pulse oximetry device readily available. Avoiding any open flame or heat. This includes an oven, stovetop, candles, matches, and cigarettes. Flammable products such as alcohol and oil should be avoided. Have working smoke detectors in the home as well as fire extinguishers. Use a water-soluble jelly to lubricate the nasal passages and mouth to prevent drying.

heat stroke

Heat stroke occurs when the client's cooling measures fail, and the core body temperature is more than 104°F (40°C). The client will experience altered mental status, anxiety, bizarre behavior, hallucinations, hypotension, hypoxia, tachycardia, tachypnea, adventitious lung sounds, abnormal blood clotting, and pulmonary injury, such as pulmonary edema because of the shifting fluid caused by critically low sodium. The pulmonary edema reveals abnormalities on the CXR.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who reports trouble sleeping at night. Which question is most important for the nurse to ask?

How many pillows do you sleep on at night? Orthopnea is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Asking the client how many pillows they use to sleep on is a way to assess if the client has been educated about measures to prevent orthopnea. COPD causes blocked or narrowed airways that make breathing more difficult. Clients may experience symptoms like wheezing, coughing, mucus production, and tightness in the chest. Smoking or exposure to harmful chemicals can cause COPD. Orthopnea is a common symptom of COPD clients. ✓ Beyond the number of pillows, assess the client for orthopnea, which is difficulty breathing while lying flat. This may provide additional insights into the severity of respiratory distress during sleep. ✓ Inquire further about the client's overall sleep quality, including the presence of any other sleep disturbances or interruptions. Understanding the broader context of the sleep experience can help identify contributing factors. ✓ There is a significant overlap between sleep apnea and COPD. Studies suggest that a substantial proportion of individuals with COPD also experience sleep apnea. The coexistence of these conditions can have additive effects on respiratory function and overall health.

acute respiratory distress syndrome (ARDS)

Inflammation from pneumonia may cause a client to develop ARDS. A classic manifestation of ARDS is hypoxemia (PaO2 less than 80 mm Hg). Adventitious lung sounds are not normally auscultated initially with ARDS and are not a reliable assessment. Treatment for ARDS is correcting the underlying cause and maintaining adequate oxygenation and ventilation via invasive and non-invasive means. The normal PaO2 is 80-100 mm Hg, and the normal SpO2 is greater than 95%.

The nurse is developing a plan of care for a client admitted P. aeruginosa pneumonia. Which of the following should the nurse include in the client's plan of care?

Initiate a vascular access device and encourage by-mouth fluids. Initiating vascular access is essential for a client admitted with P. aeruginosa pneumonia because parenteral antibiotics are the mainstay of treatment. Dehydration is common in pneumonia, and encouraging non-caffeinated fluids is beneficial. ✓ For a client with P. aeruginosa pneumonia, the nurse should initiate droplet precautions and maintain airway patency. ✓ The biggest complication associated with pneumonia is acute respiratory distress syndrome or sepsis. ✓ Obtaining blood cultures, providing pulmonary hygiene, and initiating prescribed antibiotics are essential in managing pneumonia.

Which of the following should be included when teaching a 65-year-old male client with COPD about exercise? Select all that apply.

Instruct the client to avoid sudden position changes that may cause dizziness. Instruct the client to avoid exercising in very cold or very hot temperatures. Teaching points for exercising in patients with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures.

Losartan is an angiotensin receptor blocker (ARB)

It reduces systemic blood pressure (afterload) by countering angiotensin II. Losartan does not have direct inotropic action on the heart, but it helps the cardiac output by decreasing the afterload. Losartan improves the morbidity and mortality in heart failure, and hence it's an important drug in treating heart failure.

The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include?

Keep a pulse oximetry device readily available. Pad the tubing in areas that put pressure on the skin. Have a sign on your door indicating the presence of oxygen. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames.

The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % What is the priority action for the nurse to take at this time?

Keep the child calm and call for emergency airway equipment Any child presenting with excessive drooling, distress, and stridor is highly suspicious of having epiglottitis. In addition, this client is already showing signs of circulatory compromise, including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing the airway, and the airway is always the priority.

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis inspiratory stridor

Laryngotracheobronchitis

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take?

Notify the rapid response team (RRT). This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider.

The nurse is assessing a client with a chest tube for crepitus. Which assessment technique is most appropriate for the nurse to perform?

Palpate the skin around the chest tube and observe for a crackling sensation. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of the skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space.

The new nurse is preparing a client for a thoracentesis. Which of the following actions by the new nurse requires follow-up by the charge nurse?

Place the client in semi-Fowler's position. A thoracentesis is best performed with the client sitting upright and leaning slightly forward with arms supported. Unless there is a large volume of fluid in the pleural space, thoracentesis usually takes 10 to 15 minutes. During this time, most clients sit quietly on the edge of a chair or bed with their head and arms resting on a pillow positioned on a bedside table. Semi-Fowler's position is not utilized.

pneumonia

Pneumonia is an infectious condition caused by bacteria, viruses, or fungi. Pneumonia may cause an individual to experience dyspnea, fever, lethargy/fatigue, tachypnea, productive cough, adventitious lung sounds, anorexia, and hypoxia. Pneumonia will cause abnormalities on the chest x-ray (CXR), including consolidation, opacities, and infiltrates. A fever is present in pneumonia, which is not in pulmonary edema.

The nurse is assessing a client immediately following a thoracentesis. The nurse understands that the most common complication following this procedure is a

Pneumothorax The most common complication associated with thoracentesis is a pneumothorax. The nurse should assess the client for this adverse reaction which includes the client experiencing tachypnea, coughing, decreased or absent lung sounds on the affected side, and decreased blood oxygen levels.

The nurse is working with a 17-year-old client diagnosed with cystic fibrosis. Which of the following is the most important for clients of this age with cystic fibrosis?

Promoting independence in decision-making by including the client in their care.

The nurse is assessing a client who has a pneumothorax. Which of the following assessment findings should the nurse expect?

Reduced breath sounds on the affected side A pneumothorax has clinical features such as reduced breath sounds on the affected sides, tachypnea, dyspnea, and pleuritic chest pain. Some clients may be asymptomatic, depending on the size of the pneumothorax.

RAAS system activation in heart failure

Reduced renal blood flow stimulates renin release. Renin converts Angiotensinogen to Angiotensin I, which is further activated to Angiotensin II by the angiotensin-converting enzyme in the lungs. Angiotensin II is a vasoconstrictor, and it increases peripheral vascular resistance (afterload). When medications are used to reduce afterload, the heart pumps better, and cardiac output increases.

The nurse is caring for a client who is admitted to the emergency department with acute respiratory distress. The primary healthcare provider (PHCP) orders a chest X-ray, arterial blood gas analysis, and initiation of non-invasive positive pressure ventilation (NIPPV). What is the primary goal of using NIPPV in this client?

Reducing the work of breathing and improving ventilation NIPPV, including methods such as bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP), is used to support ventilation, decrease respiratory muscle fatigue, and improve overall respiratory function.

The nurse is caring for a client with a pulmonary embolism (PE). Which of the following findings require immediate follow-up?

Restlessness Restlessness is an ominous sign suggestive of hypoxia. Hypoxia indicates pulmonary embolism (PE) that is advancing, and the client is becoming unstable. The nurse should immediately follow up on this finding. Pulmonary embolism (PE) risk factors include venous thromboembolism, hypercoagulability, immobility, and smoking. Most PEs arise from an untreated deep vein thrombosis (DVT) that may be lethal if it goes unrecognized. Manifestations of PE include pleuritic chest pain, cough, and dyspnea.

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to:

Stop the urokinase and call the physician You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis sudden onset of symptoms

Streptococcal pharyngitis, Epiglottitis,

For each assessment finding below, click to specify if the finding is consistent with the disease process of epiglottitis, laryngotracheobronchitis, or streptococcal pharyngitis throat pain

Streptococcal pharyngitis, Epiglottitis,

The nurse is completing an assessment of a 6-year-old client with an asthma exacerbation. Which of the following assessment findings is of most concern to the nurse?

Sudden absence of wheezing Wheezing is expected during an exacerbation. If a client should experience a sudden absence of wheezing, this may indicate respiratory arrest. If the asthma attack improves, a gradual decrease in wheezing is expected (not a sudden cessation). ✓ Management of an asthma exacerbation involves prompt administration of oxygen and albuterol via nebulizer. ✓ Other medications indicated during an asthma exacerbation include prednisone and magnesium sulfate (which causes bronchodilation). ✓ The nurse should monitor the client for deterioration, including the sudden cessation of wheezing, decreasing oxygen saturation, and cardiac dysrhythmias.

traumatic pneumothorax

Sudden-onset chest pain Shortness of breath and difficulty breathing. Rapid and shallow breathing Cyanosis Decreased or absent breath sounds on the affected side of the chest during auscultation. Tachycardia ✓ Management of Traumatic Pneumothorax will vary from client to client and can be as simple as observation or as complex as surgery. ✓ Traumatic pneumothorax is a serious medical emergency that requires prompt evaluation and appropriate management. Early recognition and intervention can lead to better outcomes and prevent potential complications associated with lung collapse and respiratory compromise.

A nurse is caring for a client who recently experienced a non-fatal drowning. The client is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process?

Water washing out the alveolar surfactant. Aspiration of salt water or fresh water can lead to surfactant washout, disrupting the alveolar-capillary membrane and increasing its permeability. Surfactant reduces surface tension within the alveoli, increases lung compliance and alveolar radius, and decreases the work of breathing. The loss of surfactant destabilizes the alveoli, causing increased airway resistance. Following the aspiration of salt water or fresh water and the associated surfactant washout, the client is at significant risk of pulmonary edema. ✓ The primary goal of treating pulmonary edema is to address the underlying cause. ✓ Immediate interventions may include providing supplemental oxygen, administering diuretics to reduce fluid overload, and using medications to improve cardiac function and blood flow (if needed). ✓ The duration of submersion and extent of hypoxic injury predicts the ultimate clinical course. ✓ Antibiotics should be reserved for cases of clinical pulmonary infection (e.g., fever, leukocytosis, etc.) or if the client was submerged in grossly contaminated water.

The nurse is providing discharge instructions to a client with a tracheostomy. Which of the following instructions should the nurse include?

Wear a shower shield over the tracheostomy when bathing. A shower shield should be placed over the tracheostomy when the client bathes. This would prevent water from entering the tracheostomy and potentially lead to pneumonia.

The nurse is preparing a child with cystic fibrosis for chest physiotherapy (CPT). Prior to performing the prescribed CPT, the nurse should

administer the prescribed bronchodilator. The nurse should administer the prescribed bronchodilator prior to CPT being performed. The bronchodilator should be administered 15-30 minutes before CPT. Administering the bronchodilator first will facilitate the passage of the mucous. ✓ The purpose of CPT is to loosen secretions ✓ CPT can be performed by manual percussion or specialized vests ✓ The prescribed bronchodilator should be administered 15-30 minutes before CPT to facilitate the passage of the mucous ✓ CPT should be performed at least 30 minutes before meals to increase the palatability of the meal ✓ Contraindications to CPT include rib fractures, increased intracranial pressure, and if the client is being anticoagulated

The nurse is planning care for a child who has had a near drowning at a local swimming pool. It would be a priority for the nurse to have which item at the bedside?

advanced airway Drowning may cause a catastrophic pulmonary injury, and maintaining the client's airway to deliver warm, humidified oxygen is essential. While thermoregulation needs to be attained (drowning results in a decrease in body temperature), the essential item to have is airway equipment. Restoring a client's airway will prevent a serious complication of an anoxic brain injury.

The emergency department nurse is caring for a child with an exacerbation of asthma The nurse should immediately obtain a prescription for _______ The goal of this medication is to cause ________

albuterol bronchodilation

The nurse in a pediatrician's office is following up on an 8-year-old with asthma diagnosed with allergic rhinitis by the nurse practitioner who prescribed an intranasal corticosteroid and an intranasal antihistamine. The highest-risk outcome associated with allergic rhinitis for this child is:

an asthma attack Allergic rhinitis can trigger airway inflammation and bronchoconstriction, leading to an increased risk of an asthma attack. Therefore, an asthma attack is the highest-risk outcome to be concerned about in this scenario. Proper management of both conditions, including the use of prescribed intranasal corticosteroids and antihistamines, is crucial to reduce this risk.

Tracheostomies

are common surgical procedures used for long-term airway management that involves creating a permanent connection between the anterior neck and trachea. Indications include upper airway obstruction, prolonged mechanical ventilation, long-term management of secretions, severe obstructive sleep apnea, and/or head/neck surgery. Tracheostomies are placed inferior to the cricothyroid membrane, most commonly between the second and third tracheal rings. For mechanically ventilated clients, tracheostomies generally occur between days 7 and 21 of mechanical ventilation.

course crackles

are lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways, likely to change with coughing or suctioning.

The nurse is performing a physical assessment on an adult client. The nurse should assess for tactile fremitus by

asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the client repeats "ninety-nine" to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up.

The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure?

assess Respiratory status Respiratory complications following rapid removal of fluid include hypoxemia and pulmonary edema. Assessing the client's respiratory status is a high priority and would be the first action the nurse should take. ✓ Following a thoracentesis, immediate assessments include the client's vital signs and listening to the lungs for absent or reduced sounds on the affected side (this could indicate a pneumothorax). ✓ Check the puncture site and dressing for leakage or profuse bleeding. Scant drainage is expected. ✓ Assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. ✓ Instruct the client to breathe deeply to promote lung expansion.

The nurse is caring for a 16-year-old client with cystic fibrosis. The client develops a temperature of 101.2° F (38.4° C). The nurse should obtain a prescription for

azithromycin Administering azithromycin (antibiotic) is the top priority for a client with cystic fibrosis (CF) who develops a fever. Due to the excessively thick mucus that builds up in their bronchi and bronchioles, individuals with CF are incredibly susceptible to respiratory infections. A fever indicates infection and aggressive management is the top priority.

The nurse is caring for a client with a chest tube for the treatment of a pneumothorax. Which item is essential to have at the bedside?

bottle of sterile water The chest tube is usually connected to an underwater seal system. The underwater seal system restores appropriate pressure to the lungs, facilitates the air to exit from the pleural space on exhalation, and prevents it from reentering the pleural cavity during inhalation. A chest tube disconnected from the underwater seal system is a medical emergency. A bottle of sterile water is essential to have at the bedside because if the chest tube becomes disconnected from the chest tube system, the nurse can maintain the patency of the system by putting the end of the tube in sterile water, which will prevent air from reentering the pleural space.

A nurse is caring for a client who, within the last three hours, received a pneumothorax diagnosis and had a chest tube placed. Upon assessment, the nurse observes no tidaling in the water seal chamber. Which of the following actions would be most appropriate for the nurse?

check tubing for kinks Tidaling in the water seal chamber and intermittent bubbling are expected for a client with a pneumothorax. If tidaling and intermittent bubbling have stopped, it could indicate a positive finding, such as the resolution of the pneumothorax. Considering this client had this device placed three hours ago, the resolution of the pneumothorax is unlikely. A more likely scenario is that a portion of the tubing is kinked or obstructed, which has stopped the tidaling in the water seal chamber. The easiest, least invasive, and quickest assessment the nurse can perform while walking to the client's bedside is a visual assessment of the chest tube tubing to assess whether a kink is present in the chest tube tubing, resulting in a ceasing of the tidaling.

The nurse is teaching a health promotion class to a group of community members on preventing chronic obstructive pulmonary disease (COPD). The nurse should emphasize that a significant risk factor for COPD is

cigarette smoke The most significant risk factor for COPD is cigarette smoking. Cigarette smoking causes airway obstruction via the destruction of elastin and collagen, contributing to the development of COPD. The nurse should remind community members that several prescribed medications are available to cease cigarette smoking. Treatments include bupropion, varenicline, and nicotine replacement therapy. ✓ Common symptoms of COPD include shortness of breath, chronic cough, sputum production, wheezing, and chest tightness. ✓ In COPD, the airways become partially blocked, reducing airflow in and out of the lungs. ✓ COPD may cause airway remodeling, leading the client to develop a barrel chest. ✓ COPD is diagnosed based on medical history, physical examination, pulmonary function tests, and imaging studies.

wheezing

creates squeaky, musical, continuous sounds associated with air rushing through narrowed airways; it may be heard without a stethoscope. Wheezes originate from the small airways and usually do not clear with coughing. Treatment for wheezing is bronchodilators and inhaled anticholinergics.

The nurse preceptor supervises a new nurse caring for a child with epiglottitis. Which action by the new nurse would require the nurse preceptor to intervene? The new nurse

obtains a throat culture Obtaining a throat culture would require immediate follow-up because this may cause acute laryngospasm leading to respiratory obstruction. The culture may be obtained once an artificial airway has been established.

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign?

diminished breath sounds A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema.

The nurse is assessing a client who has sustained a blunt chest injury. Which of the following findings would support a diagnosis of pneumothorax?

diminished breath sounds Diminished or absent breath sounds in the affected area are an expected finding with pneumothorax. This is because air has entered the pleural space and collapsed that portion of the lung making it ineffective in gas exchange.

Pulmonary function tests (PFTs)

do not require any sedation or invasive machinery and may be done at the bedside. The purpose is to assess lung function and breathing problems. ✓ These tests measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and ventilation distribution. The results are interpreted by comparing the client's data with expected findings for age, gender, race, height, weight, and smoking status. ✓ Some PFTs may require specific preparation, such as avoiding certain medications or fasting for a few hours before the test. Client's should follow their healthcare provider's instructions to ensure accurate and reliable test results.

epiglotitis

has manifestations that have an abrupt onset that may progress rapidly. Various pathogens may cause epiglottitis, but the most common one is Haemophilus influenzae. The manifestations associated with epiglottitis include dysphagia, inspiratory stridor that is worse when the child is supine, restlessness, high fever, tachycardia, and tachypnea. The voice is thick and muffled, with a froglike croaking sound on inspiration. This condition may be life-threatening if not treated with antibiotics, humidified oxygen, corticosteroids, and parenteral fluids. Airway protection is essential because it may become so progressive that it causes airway obstruction. Epiglottitis does not feature a cough which is a crucial distinguishment between laryngotracheobronchitis. The client in the scenario has epiglottitis which is severe, as evidence by the hypoxia

Streptococcal pharyngitis

has manifestations that have an abrupt onset. These manifestations include fever, headache, malaise, throat pain, cervical lymphadenopathy, reddened tonsils, and exudate covered on the tonsils. This illness is caused by group A β-hemolytic streptococci and is treated with prescribed antibiotics (azithromycin, penicillin) and over-the-counter pain medication such as ibuprofen. Antibiotic therapy needs to be completed because it may consequently lead to glomerulonephritis. This condition does not feature inspiratory stridor, restlessness, muffled voice, or stridor because it does not extend beyond the throat or feature significant edema causing airway compromise.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding?

headache CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death. ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

The nurse is caring for a 10-year-old client with a tracheostomy tube. The nurse notices that the client has a large amount of secretions and prepares the client for suction. Which action should the nurse take first?

hyperoxygenate the client It is necessary to hyper-oxygenate the client prior to taking any of the other actions. This is one of the first steps in suctioning a tracheostomy. The nurse hyper-oxygenates the client to prepare them for the procedure and prevent oxygen desaturation. The nurse then inserts the suction catheter without suctioning to the pre-measured depth, applies intermittent suction, and rotates the suction catheter while removing it from the tracheostomy.

Neprilysin system in heart failure

independent of the RAAS system, another system called the Neprilysn system is also critical in heart failure. In heart failure, natriuretic peptides (brain natriuretic peptide and atrial natriuretic peptide) and bradykinin are released. The natriuretic peptides are helpful in heart failure because they cause natriuresis and diuresis. However, neprilysin in the body degrades these favorable peptides. Additionally, neprilysin also degrades angiotensin II. Inhibiting neprilysin will increase both angiotensin II and natriuretic peptides. In this case, inhibiting neprilysin while also inhibiting angiotensin will produce the best results. Therefore, a new class of combination drugs called angiotensin receptor-neprilysin inhibitors (ARNI) is now preferred in clients with heart failure with reduced ejection fraction. An example of an ARNI is sacubitril -valsartan (Entresto) In clients who can not tolerate an ARNI, an ARB or ACEI can be used.

Epiglottis

is a cartilaginous flap present at the back of the throat. It's primary function is to close over the airway during swallowing so that the food does not enter the airway. Acute epiglottitis is a medical emergency that has an abrupt onset. In epiglottitis, the epiglottis becomes inflamed and swollen and obstructs the airway. Classic symptoms of epiglottis include - Sore throat and pain in swallowing Fever The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva Red and inflamed mucous membranes Large, cherry red, edematous epiglottis Prevention : Key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at two months of age.

Asthma

is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing. These episodes, often referred to as asthma attacks, can range from mild to severe and may be triggered by various factors. ✓ Monitor the child's respiratory rate, heart rate, oxygen saturation, and overall respiratory effort. This helps in promptly identifying any signs of respiratory distress. ✓ Asthma treatment often involves long-term control medications to reduce inflammation (such as inhaled corticosteroids) and bronchodilators for quick relief during acute episodes, in addition to identifying and avoiding triggers as an essential part of asthma management. ✓ Diagnosis of asthma is typically based on a combination of medical history, physical examination, and pulmonary function tests, such as spirometry, to assess lung function.

Polycythemia (PV)

is a condition in which the number of RBCs in the blood is greater than normal. The blood hemoglobin levels in PV are sustained at greater than 16.5 g/dL in men or greater than 16.0 g/dL in women (WHO definition of polycythemia). Polycythemia may be primary (bone marrow problem such as myeloproliferative disorder), secondary (COPD, EPO producing tumors), or relative (dehydration). Patients with COPD commonly have secondary polycythemia caused by hypoxia, which prompts erythropoiesis (red cell production).

Stridor

is a medical emergency and indicates that the upper airways (larynx or pharynx) are closing.

cystic fibrosis

is a multisystem disorder that is caused by a genetic defect. This disorder is inherited as an autosomal recessive trait. ✓ Meconium ileus is one of the earliest manifestations in an infant with cystic fibrosis. This may occur within the first two weeks of life. Manifestations of a meconium ileus include abdominal distension and failure to pass meconium, with or without vomiting. ✓ Treatment includes nasogastric tube (NGT) insertion, which may decompress the abdomen.

chest tube

is a primary treatment for a client with a pneumothorax. The chest tube is connected to the underwater seal system. The nurse is responsible for assessing the patency of the system by assessing each chamber. The nurse should always ensure client safety by having the appropriate emergency equipment at the bedside. This equipment includes occlusive sterile gauze, a bottle of sterile water, and clamps. If the chest tube gets dislodged from the patient's chest, an occlusive dressing should be placed over the site, and the physician should be notified. If the tubing becomes disconnected from the underwater seal system, the tubing should be promptly inserted into the bottle of sterile water to maintain the patency until a new unit is set up.

Pleural Friction rub

is characterized by loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together, often associated with pain on deep inspirations.

Laryngotracheobronchitis (croup)

is commonly caused by a viral infection (influenza types A and B, adenovirus, RSV, and measles) that is slowly progressive. It typically features a brassy (barking) cough, hoarseness, restlessness because of the frequent coughing, low-grade fever, and inspiratory stridor. Treatment is with corticosteroids, fluids, and nebulized epinephrine in severe cases. Laryngotracheobronchitis does not feature a primary complaint of throat pain or dysphagia. The common feature of this condition is that the client sounds worse than they feel. This condition does not feature drooling or difficulty while in the supine position

Atelectasis

is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/impaired oxygenation. Post-operatively, the client may not be able to take deep breaths due to pain from the movement of abdominal muscles. This impaired expansion of the alveoli leads to the accumulation of secretions/mucus plug, decreased surfactant, as well as the obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis

Rhonchus (rhonchi)

is lower in pitch and sounds like continuous snoring. These sounds arise from the large airways and usually can be cleared with coughing.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who

is recovering from a thoracentesis and reports a nagging cough Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed.

Thoracentesis

is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes. This test can be performed at the bedside and typically involves using ultrasound to guide the needle. Nursing considerations for this procedure involve witnessing the informed consent, positioning the client over a bedside table, and supporting the client during the procedure. The provider will insert a needle (after the skin has been anesthetized) attached to a syringe and will slowly aspirate fluid. This fluid may be sent for laboratory analysis. A sterile pressure dressing will be applied, and a follow-up chest x-ray will be performed. The most common complication following this procedure is a pneumothorax.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) with a chronically increased red blood cell count (RBC). The nurse understands that this finding is likely from

low blood oxygen levels Polycythemia is a condition with increased red blood cells in the blood. Low blood oxygen levels, a clinical feature associated with COPD, cause the kidneys to respond by releasing erythropoietin (EPO), which stimulates red blood cell production. The red blood cell count is elevated to compensate for hypoxia or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen.

pneumothorax

may be caused by chest wall trauma, insertion of a central vascular access device (subclavian or intrajugular), severe pulmonary tuberculosis, and cystic fibrosis ✓ Pneumothorax causes a loss of negative pressure in the pleural space, leading to the collapsing of the lung that causes a reduction in vital capacity ✓ Manifestations of a pneumothorax include reduced or absent breath sounds on the affected side, tachypnea, tachycardia, and hyper resonance on chest percussion ✓ Nursing care includes applying supplemental oxygen and the preparation of the physician inserting a chest tube ✓ Pneumothorax is diagnosed by chest radiograph (x-ray)

The nurse is caring for a client with carbon monoxide (CO) poisoning. The nurse anticipates administering oxygen via

nonrebreather mask. CO poisoning requires aggressive oxygenation at a FiO2 of 100%. A nonrebreather is the only delivery device to provide a FiO2 level of 100% and is used for a client with CO poisoning.

The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action?

notify HCP

Following a persistent cough, chills, and fever, a client was admitted for a possible respiratory infection. The admission orders include a regular diet, vital signs every 4 hours, ampicillin 250 mg PO every 6 hours, and sputum culture. Before beginning antibiotic therapy, the nurse should perform which of the following?

obtain a sputum culture When caring for a client requiring a sputum culture, the sputum sample should be obtained before initiating antibiotic therapy. Obtaining the sputum sample prior to initiating antibiotic therapy allows for accurate detection of the organism(s) causing the infection through the sputum culture. In this case, the client presented with a generalized respiratory illness. The admission orders included obtaining a sputum culture and initiating a powerful, broad-spectrum antibiotic (i.e., ampicillin). The sputum culture (and subsequent sensitivity) will be sent to the lab, where it will develop and reveal what specific organism is causing the infection. Once the organism has been identified, the health care provider (HCP) will switch the broad-spectrum antibiotic (i.e., ampicillin) to an antibiotic chosen to target the identified affecting organism. Conversely, if the ampicillin is initiated prior to the collection of the sputum culture, a decrease of the culture sensitivity occurs, resulting in a loss of data. This data loss jeopardizes the ability of the sputum culture tests to accurately pinpoint what organism to target, resulting in a decreased ability to accurately determine the most effective antibiotic(s).

The nurse is caring for a client with a suspected pulmonary embolism. After the nurse notifies the rapid response team, the nurse should perform which action?

obtain vital signs place the client in the high-Fowler's position The nurse needs to obtain vital signs because a client with a suspected pulmonary embolism may experience hypoxia, tachypnea, and tachycardia. The nurse can intervene by providing supplemental oxygen if the vital signs show hypoxia. Finally, the nurse will need to notify the physician, and having recent vital signs is essential to determine the client's overall stability.

The nurse is caring for a client who had a thoracentesis two hours ago. Which assessment finding requires follow-up?

persistent cough The most immediate postoperative risk factor is pneumothorax. Thoracentesis is when a needle is inserted into the pleural space between the lungs and the chest wall. This procedure removes pleural effusion (excess fluid) from the pleural space to help ease breathing. The risks of this procedure may include air in the area between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare). Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and frequent coughing.

The nurse is caring for a client with pneumothorax with a chest drainage system in place. On assessment, the system has become dislodged from the client. The nurse should initially

place an occlusive dressing over the site and tape on three sides. The dislodgment of a chest tube is considered an emergency. The nurse's initial intervention should be to immediately apply an occlusive dressing to the site when the client exhales. The nurse should tape it on three sides to prevent a tension pneumothorax. Once a dressing is in place, the nurse should send a colleague to notify the health care provider (HCP) immediately while remaining with the client and closely monitoring the client's vital signs and respiratory status. ✓ Emergency supplies should be readily available at the bedside, including an occlusive dressing, a bottle of sterile water, and a clamp ✓ The chest drainage system should always be kept below the insertion site ✓ The chest drainage system should never be routinely clamped ✓ The tubing is temporarily clamped when changing out the collection chamber

For each client finding below, click to specify if the finding is consistent with the disease process of pulmonary edema, heat stroke or pneumonia abnormal chest radiograph (x-ray) findings

pneumonia, pulmonary edema, heat stroke

For each client finding below, click to specify if the finding is consistent with the disease process of pulmonary edema, heat stroke or pneumonia crackles in lungs

pneumonia, pulmonary edema, heat stroke

For each client finding below, click to specify if the finding is consistent with the disease process of pulmonary edema, heat stroke or pneumonia hypoxia

pneumonia, pulmonary edema, heat stroke

For each client finding below, click to specify if the finding is consistent with the disease process of pulmonary edema, heat stroke or pneumonia tachypnea

pneumonia, pulmonary edema, heat stroke

You receive the change-of-shift report for an infant whose family has just been informed of the infant's cystic fibrosis diagnosis. As the nurse caring for this pediatric client and the family, which of the following should you prioritize?

provide emotional support for the family Following the recent diagnosis of a chronic and incurable genetic condition such as cystic fibrosis, this family will require significant emotional support. Throughout the shift, the parents will likely have numerous questions regarding the need to follow up on genetic counseling, treatment options, prognosis, and/or resources

For each client finding below, click to specify if the finding is consistent with the disease process of pulmonary edema, heat stroke or pneumonia oral temperature of 97° F (36° C)

pulmonary edema

The nurse is designing a care plan for a client scheduled for a total laryngectomy. The nurse plans on consulting which discipline in this client's care plan?

respiratory therapy A total laryngectomy is the removal of the larynx and surrounding lymph nodes. This is a significant procedure that requires the placement of a tracheostomy. The client will need an interdisciplinary approach to their care. A central figure for a client with a tracheostomy is a respiratory therapist collaborating with the nurse regarding tracheostomy management. ✓ After a total laryngectomy, the client will have a tracheostomy placed. ✓ The nurse can expect the client to require more frequent suctioning with a brand-new tracheostomy, and the secretions may be bloody for the first few days. ✓ Respiratory therapy is often consulted to assist in caring for the tracheostomy.

The nurse is completing a home assessment for a client receiving oxygen therapy. Which essential piece of equipment should be available?

smoke detector It is essential that a client receiving oxygen therapy have smoke detectors and a fire extinguisher as oxygen therapy enhances combustion. Having functional smoke detectors and a fire extinguisher is a priority because it promotes client safety.

fine crackles

sound like popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear.

The nurse is assessing an infant with suspected cystic fibrosis. Which of the following signs and symptoms would the nurse recognize as supporting this diagnosis? Select all that apply.

steatorrhea - Steatorrhea is a symptom of cystic fibrosis (CF). Steatorrhea is fatty, frothy stools that occur due to fat malabsorption. In CF, the body produces thick, sticky mucus that clogs up the body and interferes with the absorption of many things, including fat. Due to this, fat passes through the digestive tract without being absorbed and is excreted in the form of steatorrhea. meconium ileus- Meconium ileus is a symptom of CF and is often the first sign of CF in an infant. Meconium ileus is when infants cannot pass their first stool (meconium). In CF, the thick, sticky mucous has clogged up the body, making it difficult for the infant to pass their first stool. salty sweat- Salty-tasting sweat is a symptom of CF. A lot of sodium is lost through the sweat, making it taste salty. This increases the risk for hyponatremia and is one of the first things parents might notice about their infant born with CF. adventitious breath sounds - Adventitious breath sounds are a symptom of CF. Rhonchi may be auscultated because of the thick amount of mucous in the airway. Other lung sounds associated with CF include wheezing.

Pneumothorax may be caused by

trauma to the chest wall secondary to a traumatic injury. Pneumothorax may also adversely develop during the placement of a subclavian or intrajugular central line. The priority treatment for clients unstable with pneumothorax is the placement of a chest tube.

Thorocentesis

✓ A thoracentesis is used to remove air or fluid from the pleural space ✓ Informed consent is required for this procedure ✓ This procedure is performed at the bedside by the provider using local anesthetic ✓ The most common complication following this procedure is pneumothorax or hemothorax ✓ Manifestations of a pneumothorax include tachypnea, tachycardia, decreased oxygen saturation, diminished/absent breath sound on the affected side and coughing, ✓ It has been standard practice at many facilities to obtain a chest x-ray after thoracentesis to rule out pneumothorax, document the extent of fluid removal, and view lung fields previously obscured by fluid

influenza

✓ Droplet precautions should be implemented for clients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a client is in a healthcare facility. ✓ No influenza vaccine causes the illness ✓ The LAIV is recommended for individuals 2 through 49 years old ✓ The IIV is recommended for individuals older than 6 months ✓ The IIV is safe for individuals who are pregnant

respiratory acidosis

✓ The causes of respiratory acidosis include pulmonary emphysema, obstructive sleep apnea, atelectasis, and hypoventilation ✓ Treatment is aimed at the underlying cause, including instructing the client to turn, cough, and breathe deeply ✓ An incentive spirometer may also be used to help treat respiratory acidosis