respiratory

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom?

Chest pain that occurs suddenly

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply.

3.Hypotension 5.Use of peripheral vasoconstrictors

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

1.Check vital signs 3.Notify the registered nurse 4.Begin low-flow oxygen therapy.

Which are signs and symptoms characteristic of emphysema? Select all that apply.

1.Cyanosis 3.Weight loss 4.Barrel chest 5.Shortness of breath 6.Decreased lung sounds

The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply.

1.Elastoplast tape 3.Sterile 4 × 4 gauze pads 4.Povidone-iodine solution 5.Petrolatum (Vaseline) gauze

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply.

1.Enables the client to speak 3.Must have the cuff deflated when capped

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

1.Loss of smell 2.Chronic cough 3.Nasal stuffiness

A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply.

1.Mental changes 2.Cardiac irregularities 3.Cherry-red skin color

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply.

1.Notify the RN. 4.Discontinue suctioning until the client is stabilized.

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 second

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

A]

A client arrives in the emergency department with a bloody nose. Which is the initial nursing action?

Assist the client to a sitting position with the head tilted slightly forward.

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?

Bilateral wheezing

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 hours

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

Check the client for spontaneous breathing.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Check the client.

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

Check the client.

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

Inspect chest tube connections.

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

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

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Sitting up with elbows resting on knees 4.Lying on his or her back in low-Fowler's position

Lying on his or her back in low-Fowler's position

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurological disorders

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Refer to audio.) The nurse determines that these breath sounds usually result from which cause?

Opening of small airways that contain fluid

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

Places the stethoscope on the client's gown

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

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?

Shortness of breath

The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation?

The behavior is likely the result of hypoxia.

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?

The client is breathing through the nose.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays?

The protective mechanism of the nose may be damaged.

The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan which as a final measure to determine correct tube placement?

Verify placement by a chest x-ray.

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

"To allow for reexpansion of the lung."

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.

2.Dyspnea during exertion 3.Presence of a productive cough 4.Difficulty breathing while talking

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

2 L/min

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective?

Breath sounds are now clear.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note?

Hyperinflated lungs on chest x-ray

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? 1.Monitoring the client's airway 2.Applying manual pressure over the site 3.Lowering the head of the bed to a flat position 4.Calling the primary health care provider immediately

Lowering the head of the bed to a flat position

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next?

Notify the registered nurse (RN).

A client with pneumonia is admitted to the hospital, and the primary health care provider writes prescriptions for the client. Which prescription should the nurse complete first?

Obtain a culture and sensitivity of sputum.

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

Report the findings.

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?

The tube may be occluded.

The nurse is caring for a client with fractured ribs. Which statement indicates a need for further teaching?

"My ribs will be healed in a month."

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?

Obturator

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendations by the nurse are therapeutic? Select all that apply.

1.Get plenty of rest. 2.Take antipyretics for fever. 3.Increase intake of liquids.

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?

mask

The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth?

oral airway

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

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