Respiratory Disorders
The nurse is assessing a client who is being treated for bacterial pneumonia. Which is an expected finding for this client? a maximum loss of 5 to 10 lb (2 to 5 kg) of body weight chest pain that is minimized by splinting the rib cage a respiratory rate of 25 to 30 breaths/min the ability to perform activities of daily living without dyspnea
the ability to perform activities of daily living without dyspnea Explanation: An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2.3 to 4.5 kg) is undesirable; the expected outcome would be to maintain a normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client: wants the head of the bed raised to a 90-degree level. has a pulse oximetry reading of 91%. uses the sternocleidomastoid muscles. asks for an additional pillow.
uses the sternocleidomastoid muscles. Explanation: Use of accessory muscles indicates worsening breathing conditions. Asking for an additional pillow, having a 91% pulse oximetry reading, and requesting the nurse to raise the head of the bed are not indications of a worsening condition.
A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions? "The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall." "I should limit the use of the inhaler to early morning and bedtime." "It is important not to shake the canister because that can damage the spray device." "I should hold one nostril closed while I insert the spray into the other nostril."
"I should hold one nostril closed while I insert the spray into the other nostril." Explanation: When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the other nostril to ensure the best inhalation of the spray. The use of the inhaler is not limited to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation of the medication.
A competent client requiring long-term mechanical ventilation privately tells a nurse that they want the ventilator withdrawn. Which response by the nurse is best? "How does your family feel about this?" "Tell me more about how you are feeling." "I'll let your healthcare provider know your feelings." "Now that I'm here, tell me all about it."
"Tell me more about how you are feeling." Explanation: Asking the client how they are feeling uses an open-ended question that encourages the client to express their feelings. Asking the client to consider their family is judgmental and is an inappropriate statement. Ventilation can be withdrawn according to the client's wishes. The nurse stating, "Now that I'm here" is unprofessional and would be inappropriate. Contacting the healthcare provider would be premature as the nurse needs more information.
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
"Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day." The nurse should instruct the client to weigh themselves daily and report a gain of 2 lb (0.91 kg) in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy. The client shouldn't smoke at all.
A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? 10 to 20 mcg/ml 2 to 5 mcg/ml 21 to 25 mcg/ml 5 to 10 mcg/m
10 to 20 mcg/ml Explanation: The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.
The client is to receive theophylline 500 mg IV in 500 mL of normal saline solution to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse should set the infusion pump to administer the solution at how many milliliters per hour?
125 To administer IV fluids at 500 mL over 4 hours, the nurse must determine the number of milliliters to administer in 1 hour. To do so, divide 500 by 4 to arrive at 125 mL/hr.
A client with bronchitis is ordered 300 mg of liquid guaifenesin every 4 hours. The container indicates that there is 200 mg/5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.
7.5 Explanation: The following formula is used to calculate the drug dosage: Dose on hand/Quantity on hand = Dose desired/X. Plug in the values for this equation: 200 mg/5 mL = 300 mg/X = 7.5 mL
A nurse is caring for a client after an open lung biopsy. Which assessment finding requires immediate intervention? respiratory rate of 44 breaths/minute client's pain level remains 4 out of 10 after pain medication oral temperature 38.1°C (100.5°F) oxygen saturation level of 96% on 3 L of oxygen
A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen and a pain level of 4 out of 10 may be expected after an open biopsy. While a temperature of 38.1°C (100.5°F) is a concern, it does not require immediate intervention.
A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. What should the nurse instruct the client to do? Apply heat to the nasal area to control swelling. Take aspirin to control nasal discomfort. Avoid brushing the teeth until the nasal packing is removed. Avoid activities that elicit the Valsalva maneuver.
Avoid activities that elicit the Valsalva maneuver. Explanation: The client should be instructed to avoid any activities that cause the Valsalva maneuver (e.g., constipation, vigorous coughing, exercise) to reduce bleeding and stress on suture lines. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client's appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.
Which complication is associated with mechanical ventilation?
Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low partial pressure of arterial oxygen (PaO2) level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administration to a client with COPD? Increased oxygen use will cause the client to become dependent on the oxygen. High oxygen concentrations will cause coughing and dyspnea. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. Administration of oxygen is contraindicated in clients who are using bronchodilators.
High oxygen concentrations may inhibit the hypoxic stimulus to breathe. Explanation: Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually, the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Anxiety Impaired gas exchange Decreased cardiac output
Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? Assess intake and output and maintain adequate hydration. Suction the client as needed to obtain a sputum specimen for culture and sensitivity. Reassure the client that intubation and mechanical ventilation will be temporary. Monitor vital signs and oxygen saturation every 15 to 30 minutes.
Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in their respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if they do, the nurse can't predict the length of time it may be necessary.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? There is a leak in the chest tube system. An obstruction is present in the chest tube. The chest tube system is functioning properly. The client is developing subcutaneous emphysema.
The chest tube system is functioning properly. Explanation: Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.
During inspiration, which action occurs? The lungs recoil. The inspiratory muscles relax. The diaphragm descends. Alveolar pressure is positive.
The diaphragm descends. Explanation: During inspiration, inspiratory muscles contract, the diaphragm descends, alveolar pressure is negative, and air moves into the lungs. The lungs recoil during expiration.
A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take? Teach the client pursed lip breathing. Encourage the use of the incentive spirometer. Call respiratory therapy for a breathing treatment. Use a sterile suction kit to suction the client.
Use a sterile suction kit to suction the client. Explanation: The priority for this client is suctioning to remove secretions in the upper airway if the client is unable to cough adequately. The other interventions will not effectively assist the client to maintain a patent airway.
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has poor peripheral perfusion. a possible hematologic problem. left-sided heart failure. a psychosomatic disorder.
a possible hematologic problem. Explanation: SaO2 is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2 and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.
A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience GI bleeding. restlessness and seizures. acute adrenocortical insufficiency. hyperglycemia and glycosuria.
acute adrenocortical insufficiency. Explanation: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.
The nurse is instructing the client with chronic obstructive pulmonary disease (COPD) to do pursed-lip breathing. What is the expected outcome of this exercise? deeper diaphragmatic breathing improved oxygen intake stronger intercostal muscles better elimination of carbon dioxide
better elimination of carbon dioxide Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.
A nurse is assigned to triage the care of four clients. Which client should the nurse assess first?
client with a sore throat who now has a muffled voice and is drooling The clinical manifestations of a muffled voice and drooling suggest a possible peritonsillar abscess that could lead to an airway obstruction. This requires rapid assessment and potential treatment. The remaining clients are stable and have expected symptoms that correspond to their medical diagnoses. Their treatment can wait until after the determination and treatment of the airway obstruction.
After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent which outcome?
depriving the client of sufficient oxygen supply A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? dyspnea and wheezing hemoptysis and dysuria nonproductive cough and normal temperature sore throat and abdominal pain
dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must milk the chest tube every 2 hours. report fluctuations in the water-seal chamber. clamp the chest tube once every shift. encourage coughing and deep breathing.
encourage coughing and deep breathing. Explanation: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
When teaching a client with chronic obstructive pulmonary disease (COPD) to conserve energy, what instruction should the nurse give the client about breathing when lifting heavy objects? Lift the object by: inhaling through an open mouth. taking a deep breath and holding it. exhaling but before inhaling. exhaling through pursed lips.
exhaling through pursed lips. Explanation: Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider? green sputum dry cough laryngeal stridor hemoptysis
laryngeal stridor Explanation: Laryngeal stridor is characteristic of respiratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately. Green sputum indicates infection and would occur 3 to 5 days after bronchoscopy. A mild cough or hemoptysis is typical after bronchoscopy. If a tissue biopsy specimen was obtained, sputum may be blood streaked for several days.
A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important? obtaining daily weights monitoring the client for indications of constipation monitoring intake and output obtaining stool samples to test for occult blood
monitoring intake and output Explanation: Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.
A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?
pneumonia Pneumonia is the most common complication of influenza. It may be either primary influenza, viral pneumonia, or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.
A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which complication should the nurse be prepared to treat? pneumothorax bronchopneumonia sepsis clotted catheter
pneumothorax Explanation: Pneumothorax can occur from inadvertent puncture of the pleura, causing sudden chest pain and shortness of breath. Bronchopneumonia would not occur as a result of catheter contamination. Bronchopneumonia is an infection in the lung tissue. The central line is inserted in the venous system, namely the subclavian vein in this situation. The other answers are incorrect because they are not complications from central line insertions. The nurse must assess the client carefully for these complications to ensure that the parenteral nutrition is being administered safely.
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? tachycardia reduced cardiac output bradycardia increased blood pressure
reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? metabolic alkalosis respiratory acidosis metabolic acidosis respiratory alkalosis
respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.
The nurse is planning to assist the health care provider with a thoracentesis for a client who has a pleural effusion. Which position for the client would be appropriate for this procedure? sitting upright and leaning on an overbed table lying prone with the head supported by the arms side-lying with the knees drawn up to the abdomen lying supine with the arms extended
sitting upright and leaning on an overbed table Explanation: The client should be seated upright with the arms raised and crossed in front and supported by the overbed table. The client's head should rest on the arms. This position allows for outward expansion of the chest wall and promotes collection of the pleural fluid at the base of the thorax.
For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?
teaching the client how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be Ineffective breathing pattern. Impaired tissue integrity. Risk for falls. Ineffective airway clearance.
Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel, a compound fracture of the right tibia and fibula, and multiple lacerations and contusions. What is the priority nursing goal for this client?
Maintain adequate oxygenation. Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is maintaining adequate circulatory volume.
The nurse is reviewing the client's lab values. On admission, the client's arterial blood gas (ABG) values were pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/min is started. Thirty minutes later, repeat ABG values are pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). Which judgment should the nurse make about the changes in the client's blood gases?
The client's respiratory status is improving. The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective. Impending respiratory failure would be indicated by a decreasing PaO2 or an increasing PaCO2. The client is not alkalotic because the pH values are below 7.35. If the chest tube was obstructed, the client's respiratory status
An older adult is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? vegetarian diet age daily bathing osteoarthritis
age Explanation: The client's age is a predisposing factor for pneumonia; pneumonia is more common in older or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.
The nurse is assessing a client with asthma. Which finding would most likely indicate the presence of a respiratory infection? chest tightness bilateral expiratory wheezing respiratory rate of 30 breaths/min cough productive of yellow sputum
cough productive of yellow sputum Explanation: A cough that produces yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present.
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? assessing the client's environment for sanitation teaching the client about the disease and its treatment offering the client emotional support coordinating various agency services
teaching the client about the disease and its treatment Explanation: Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment.
The nurse is assessing the lungs of a client who had abdominal surgery 2 days ago and hears rhonchi. Currently, the client reports mild abdominal pain 2 hours after receiving an oral narcotic pain medication. What should the nurse do next? Assess the client's breath sounds again in 10 minutes. Assist the client to use the incentive spirometer and cough up secretions. Contact the surgeon to request additional pain medication. Ensure the client has a fluid intake to 1000 mL per shift.
Assist the client to use the incentive spirometer and cough up secretions. Explanation: The client has rhonchi indicating that there are secretions in the large airways. The nurse should assist the client to use the incentive spirometer and attempt to expectorate the secretions. Narcotic pain medication decreases the respiratory rate, and if the client reports that the pain is mild, the client likely will be able to take deep breaths and cough without requiring an increased dose of narcotic pain medication. The breath sounds will not change within 10 minutes if the client does not attempt to remove the secretions.
1130:The client is alert and oriented to person, place, time, and situation. Answers questions appropriately. Mucous membranes pink and moist, no lymphadenopathy. Regular heart rate and rhythm, no murmurs or peripheral edema noted. Radial and pedal pulses +2 bilaterally. Respirations are shallow and regular , with lung sounds diminished to the left side . The client reports 8/10 pain in the left chest, worsened with deep inspiration. 14 French catheter noted to left lateral chest attached to water seal wet suction drainage system. Constant bubbling is noted in the water seal chamber. No fluctuations after the client coughed, but the bubbling stopped after the chest tube was clamped. Crepitus was noted in the left upper chest. The gauze is clean and dry. The abdomen is soft and nontender and bowel sounds are present. Extremities are strong and equal. Bony deformities were noted on bilateral knees.
Shallow respirations are abnormal and could indicate difficulty breathing. This should be evaluated further. Diminished lung sounds are an abnormal finding and should be further evaluated. Pain associated with deep inspiration may just be a side effect of the chest tube being present, but it should be evaluated. Constant bubbling in the water seal chamber of a wet suction system is not a normal finding and requires follow-up. Crepitus to the upper left chest indicates air escaping into the subcutaneous tissue, which is abnormal and requires follow-up. Bony deformities to bilateral knees are a common finding in osteoarthritis. This finding is not concerning if the lower extremities are strong and equal.
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately? normal erythrocyte sedimentation rate leukocytosis low hemoglobin level anemia
leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. This finding is expected in a client with rheumatic fever. Laboratory data indicating anemia or a low hemoglobin level will need to be addressed but are not critical and associated with the current disease process. A marginal erythrocyte sedimentation rate would be communicated on the laboratory report.
The client is taking a corticosteroid inhalant to treat bronchial asthma. The nurse should assess the client for which side effect of this drug? oral candidiasis hyperglycemia fluid retention gastric ulcer
oral candidiasis Explanation: Acetonide inhalant is a corticosteroid. Use of a steroid inhaler can cause the client to develop oral candidiasis (thrush). It is important that the client rinse their mouth after using the inhaler.Acetonide inhalant does not lead to the development of systemic complications such as hyperglycemia, ulcers, or fluid retention.
Arterial blood gas analysis would reveal which finding related to acute respiratory failure? PaO2 80 mm Hg pH 7.24 PaCO2 32 mm Hg pH 7.35
pH 7.24 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with a decreased arterial pH.
The nurse has received lab reports for several clients undergoing care. Which set of arterial blood gas (ABG) results will the nurse investigate first? pH 7.34, partial pressure of arterial carbon dioxide (PaCO2) 36 mmHg, partial pressure of arterial oxygen (PaO2) 95 mmHg, bicarbonate (HCO3-) 20 mEq/L pH 7.35, PaCO2 48 mmHg, PaO2 91 mmHg, and HCO3- 28 mEq/L pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L pH 7.47, PaCO2 43 mmHg, PaO2 99 mmHg, and HCO3- 29 mEq/L
pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L Explanation: The ABG results pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L indicate respiratory alkalosis. The pH level is increased, the PaCO2 levels are decreased and the HCO3 is normal. The decreased PaO2 indicates this client is in respiratory distress. Therefore, the nurse would investigate this result first. Normal values are pH 7.35 to 7.45, PaCO2 35 to 45 mmHg, and HCO3- 22 to 26 mEq/L. Results of pH 7.35, PaCO2 48 mmHg, PaO2 91 mmHg, and HCO3- 28 mEq/L indicate a fully compensated respiratory acidosis, making this less urgent. Results of pH 7.47, PaCO2 43 mmHg, PaO2 99 mmHg, and HCO3- 29 mEq/L indicate metabolic alkalosis, which is not the priority. Results of pH 7.34, PaCO2 36 mmHg, PaO2 95 mmHg, HCO3- 20 mEq/L indicate mild metabolic acidosis, which would also be less urgent than the respiratory alkalosis.
A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? pneumothorax myocardial infarction (MI) pulmonary embolism heart failure
pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? pulmonary embolism pneumothorax myocardial infarction (MI) heart failure
pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
The nurse is caring for a client who has undergone a pulmonary lobectomy 2 days ago. Which finding indicates the client may be experiencing internal bleeding? restlessness and shortness of breath sanguineous drainage from the chest tube at a rate of 50 mL/hr during the past 3 hours urine output of 180 mL during the past 3 hours increased blood pressure and decreased pulse and respiratory rates
restlessness and shortness of breath Explanation: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate of less than 100 mL/hhr is normal in the early postoperative period. Urine output of 180 mL over the past 3 hours indicates normal kidney perfusion.
