Respiratory Disorders - PassPoint NCLEX

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg (10.7 kPa); PaCO2, 65 mm Hg (8.7 kPa); HCO3-,36 mEq/L (36 mmol/L). The nurse should assess the client for: cyanosis. flushed skin. irritability. anxiety.

flushed skin. The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg (8.7 kPa) but are associated with hypoxia.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? medication allergies swallow reflex presence of carotid pulse ability to deep breathe

swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving them anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client exhibits bronchial breath sounds over the affected area.

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg.

A client with severe acute respiratory syndrome privately informs the nurse of a desire not to be placed on a ventilator if the condition worsens. The client's partner and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to: encourage the client to consider a living will or power of attorney. ask the physician to discuss the client's prognosis with the client and the family. arrange a conference to discuss the matter with all involved. assure the client that all possible measures will be taken.

encourage the client to consider a living will or power of attorney.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? kinking of the ventilator tubing a disconnected ventilator tube an ET cuff leak a change in the oxygen concentration without resetting the oxygen level alarm

kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which statement by the nurse will be most helpful to the client? "Use a scopolamine patch to decrease secretions." "Avoid fluid intake 2 hours before sexual activity." "Place a thin piece of gauze over the tracheostomy." "Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity."

"Place a thin piece of gauze over the tracheostomy." Placing a thin piece of gauze over the tracheostomy during sexual activity will help to contain the secretions and yet allow ventilation. Although a scopolamine patch may depress the salivary and bronchial secretions, it is not recommended for long-term use and would not be indicated in this situation. Avoiding fluids before sexual activity is not recommended to decrease secretions. Washing the tracheostomy area with any deodorizing soap may cause skin irritation and place the client at risk for infection.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first? Reassure the client that the PCA system is working and will relieve pain. Request a prescription for a cough suppressant Assess the pain using a pain scale and compare to the previous assessment. Encourage the client to take deep breaths and expectorate the mucous that is stimulating the cough.

Assess the pain using a pain scale and compare to the previous assessment. Beginning immediately following surgery, the nurse should assess the client for pain frequently and note changes on the pain scale as a guide to pain management. Reassuring the client is not sufficient when the client is reporting pain. The nurse should encourage the client to cough and take deep breaths; cough suppression is contraindicated because the client must raise and expectorate retained secretions.

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion? respirations unlabored hollow sound on chest percussion decreased mucus production breath sounds clear on auscultation

breath sounds clear on auscultation Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production.

A client who has been recently extubated has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP? prothrombin time (PT) hemoglobin and hematocrit monocytes HA1c

hemoglobin and hematocrit The nurse should review the CBC with differential to evaluate the client's hemoglobin and hematocrit, which are abnormal and should be reported to the HCP. Anemia leads to decreased oxygen-carrying capacity of the blood. A client unable to compensate for the anemia may experience a profound sense of dyspnea. There has been a significant drop in the hemoglobin and hematocrit since the previous report, and these should be reported to the HCP.

With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in which position? modified Trendelenburg's position with the lower extremities elevated reverse Trendelenburg's position with the head down left side-lying position with the head elevated 15 to 30 degrees semi- to high-Fowler's position, tilted toward the right side

semi- to high-Fowler's position, tilted toward the right side Pneumothorax will cause a client to feel extremely short of breath. Semi- or high Fowler's position will facilitate ventilation by the unaffected lung. Positioning the client toward the affected side does not compromise the remaining, functional lung. Positioning the client on the unaffected side—in this case, in the left side-lying position—compromises the remaining, functional lung and should be avoided.

A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first? the client with anorexia, weight loss, and night sweats the client with crackles and fever who reports pleuritic pain the client who had difficulty sleeping, daytime fatigue, and morning headache the client with unilateral leg swelling who reports anxiety and shortness of breath

the client with unilateral leg swelling who reports anxiety and shortness of breath The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? "I should take my bronchodilator at bedtime to prevent insomnia." "I should do my most difficult activities when I first get up in the morning." "I should try to eat several small meals during the day." "I should plan to do most of my exercises after I eat."

"I should try to eat several small meals during the day." The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals. Bronchodilators will increase insomnia. Activities should be regulated throughout the day. Eating followed by activity based on intra-abdominal pressure will increase shortness of breath.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? "I'll have to take the medication for up to a year." "This disease may come back later if I am under stress." "I'll stay in isolation for 6 weeks." "I'll always have a positive test for tuberculosis."

"I'll stay in isolation for 6 weeks." The client requires additional teaching if they state that they'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. The client will be positive when tested and if they are sick or under some stress they could have a relapse of the disease.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs? Administer the triamcinolone and then administer the salmeterol. Administer the salmeterol and then administer the triamcinolone. Allow the client to choose the order in which the drugs are administered. Monitor the client's theophylline level before administering the medications.

Administer the salmeterol and then administer the triamcinolone. A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene? A surgical face mask is applied before entering the client's room. Hand washing is performed before entering the client's room. A box of tissues is brought to the client from the supply room. A sputum culture is collected, labeled, and taken to lab as ordered.

A surgical face mask is applied before entering the client's room. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform.

A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first? Immerse the tube in sterile water. Apply an occlusive dressing such as petroleum jelly gauze. Instruct the client to cough to expand the lung. Auscultate the lung to determine whether it collapsed.

Apply an occlusive dressing such as petroleum jelly gauze. If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called. Placing the tube in sterile water will not reestablish a seal to prevent air entering the insertion site of the chest tube.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern? Cheyne-Stokes respiration hyperventilation obstructive sleep apnea Biot's respiration

Cheyne-Stokes respiration

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? Respiratory rate greater than 16 breaths/minute. Continuous bubbling in the water-seal chamber. Fluid in the chest tube. Fluctuation of fluid in the water-seal chamber.

Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The health care provider orders codeine, 10 mg PO every 4 hours. Which statement accurately describes codeine? It's a peripherally-acting antitussive and doesn't cause dependence. It's a centrally-acting antitussive and can cause dependence. It's a centrally-acting antitussive and doesn't cause dependence. It's a peripherally-acting antitussive and can cause dependence.

It's a peripherally-acting antitussive and can cause dependence. As a centrally-acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is an opioid, it can cause dependence.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? Reduce the client's anxiety. Maintain adequate oxygenation. Decrease chest pain. Maintain adequate circulating volume.

Maintain adequate oxygenation.

Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the priority nursing goal for this client? Reduce the client's anxiety. Maintain adequate oxygenation. Decrease chest pain. Maintain adequate circulating volume.

Maintain adequate oxygenation.

A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should the nurse include in the plan of care? Maintain the head of the bed at 30 to 40 degrees. Teach the client how to use esophageal speech. Initiate small feedings of soft foods. Irrigate drainage tubes as needed.

Maintain the head of the bed at 30 to 40 degrees. Immediately after surgery, the client should be maintained in a position with the head of the bed elevated 30 to 40 degrees (semi-Fowler's position) to decrease tissue edema, facilitate breathing, and decrease pain related to edema formation. Immediately postoperatively, the client should be provided alternative means of communicating, such as a communication board. As healing progresses and edema subsides, a speech therapist should work with the client to explore various voice restoration options, such as the use of a voice prosthesis, electrolarynx, artificial larynx, or esophageal speech.

A client with cancer of the throat had a tracheostomy tube inserted 2 days ago. The client has moderate secretions and can take deep breaths without pain. When suctioning a client's tracheostomy tube, what should the nurse do? Oxygenate the client before suctioning. Insert the suction catheter about 2 inches (5 cm) into the cannula. Use a bolus of sterile water to stimulate cough. Use clean gloves during the procedure.

Oxygenate the client before suctioning.

A client is in the recovery unit after surgery and is snoring with use of accessory muscles. What is the appropriate nursing intervention? Stimulate the client. Apply oxygen. Suction the oral airway. Prepare for intubation.

Stimulate the client. The client is presenting with an obstructed airway; the FIRST action would be to awaken and arouse the client and open the airway. Next the nurse would apply oxygen and suction the client. If there is no improvement, possibly this client would need to be intubated.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.

Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? The client sees their physician for a check-up yearly. The client has never traveled outside of the country. The client had a liver transplant 2 years ago. The client works in a healthcare insurance office.

The client had a liver transplant 2 years ago. A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate healthcare, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a healthcare worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

During inspiration, which action occurs? The lungs recoil. The diaphragm descends. Alveolar pressure is positive. The inspiratory muscles relax.

The diaphragm descends. During inspiration, inspiratory muscles contract, the diaphragm descends, alveolar pressure is negative, and air moves into the lungs. The lungs recoil during expiration.

A client with an endotracheal tube is being weaned from the ventilator. For which reason should the procedure be terminated? The client is awake and alert. The heart rate increased 20 beats/minute. The diastolic blood pressure decreased 6 mm Hg. The client lifts head independently off the pillow.

The heart rate increased 20 beats/minute. The weaning process should be terminated if the client experiences an adverse reaction such as increase in heart rate of 20 beats/minute.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? The water level in the humidifier reservoir is too low. The oxygen tubing is pinched. The client has a nasal obstruction. The oxygen concentration is above 44%.

The oxygen tubing is pinched.

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. Keep the client flat for at least 2 hours. Provide sips of water to moisten the client's mouth. Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Alert the client to resume food and fluids when the client's voice returns. Monitor the client's vital signs.

Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? inspection chest X-ray arterial blood gas (ABG) levels auscultation

auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise? improved oxygen intake deeper diaphragmatic breathing stronger intercostal muscles better elimination of carbon dioxide

better elimination of carbon dioxide

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

pH 7.28, PaO2 50 mm Hg 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 an arterial pH of less than 7.35.

The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube? preventing clots removing air removing fluid facilitating "milking" of the tubes

removing fluid Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of the surgical procedure. A larger-diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes to prevent clots is becoming less common; the surgeon's prescriptions must be followed regarding this procedure.

A nurse is caring for a client with influenza who becomes agitated and restless. Which nursing action is the priority? Check the client's temperature. Assess the client's lungs and check the oxygen saturation. Assess the client's level of consciousness. Notify the health care provider.

Assess the client's lungs and check the oxygen saturation.

The client is ready for discharge after surgery for a deviated septum. Which instruction would be appropriate? Avoid activities that elicit Valsalva's maneuver. Take aspirin to control nasal discomfort. Avoid brushing the teeth until the nasal packing is removed. Apply heat to the nasal area to control swelling.

Avoid activities that elicit Valsalva's maneuver. The client should be instructed to avoid any activities that cause Valsalva's maneuver (e.g., straining at stool, vigorous coughing, exercise) to reduce stress on suture lines and bleeding.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? Increase the suction level of the chest tube. Connect the client to a new chest tube system. Clamp the chest tube and document the response. Further assess the client for reinflation of the lung.

Further assess the client for reinflation of the lung. A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube.

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first? client with right-sided heart failure who has 4+ bilateral edema in the legs and feet client with a recent lung transplant scheduled to begin pulmonary rehabilitation client with a pleural effusion who reports severe stabbing chest pain client experiencing tracheal deviation following a subclavian catheter insertion

client experiencing tracheal deviation following a subclavian catheter insertion Tracheal deviation suggests possible tension pneumothorax, which is a medical emergency and needs to be evaluated immediately. Edema in a client with right-sided heart failure is a chronic condition and expected, it is not an emergency. Stabbing chest pain is expected with a pleural effusion and is also not an emergency situation. Pulmonary rehabilitation is completed by respiratory therapy and does not require the attention of the nurse.

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: stimulating the client's cough reflex. depriving the client of sufficient oxygen supply. dislodging the tracheostomy tube. obstructing the suctioning catheter with secretions.

depriving the client of sufficient oxygen supply.

An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom? ascites pleural friction rub dyspnea peripheral edema

dyspnea Dyspnea is a distressing symptom in clients with advanced cancer including metastatic carcinoma of the lung, previous radiation therapy, and coexisting COPD. Ascites does occur in clients with metastatic carcinoma; however, in the client with COPD and lung cancer, dyspnea is a more common finding. A pleural friction rub is usually associated with pneumonia, pleurisy, or pulmonary infarct.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? hypoxia delirium hyperventilation semiconsciousness

hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

The nurse is assessing a client with chronic obstructive pulmonary disease. Which finding requires immediate intervention? distant heart sounds diminished lung sounds inability to speak pursed lip breathing

inability to speak Inability to speak could indicate respiratory distress. Pulsed lip breathing, while it is an abnormal finding is not indicative of respiratory distress. Distant heart sounds could indicate heart failure but are not indicative of any distress.

A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client: lives in a long-term care facility. has no known risk factors. is immunocompromised. works as a health care provider in a hospital.

is immunocompromised.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? nausea or vomiting abdominal pain or diarrhea hallucinations or tinnitus light-headedness or paresthesia

light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? mumps impetigo measles cholera

measles

The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia? somnolence restlessness chills urgency

restlessness One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia.

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? sequestering free hydrogen ions in the nephrons returning bicarbonate to the body's circulation returning acid to the body's circulation excreting bicarbonate in the urine

returning bicarbonate to the body's circulation The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.

Which finding in a client who is receiving albuterol would require a nurse to take immediate action? stridor crackles wheezes pleural rub

stridor Stridor indicates partial airway obstruction, and requires immediate intervention. A pleural rub, crackles, and wheezes should be further assessed.

Which is an expected outcome for a client who has been treated for bacterial pneumonia? a respiratory rate of 25 to 30 breaths/min the ability to perform activities of daily living without dyspnea 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

the ability to perform activities of daily living without dyspnea 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 to 5 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. How should the nurse interpret this finding? Fluctuation means that: there is a leak in the chest tube system. there is an obstruction in the chest tube. the chest tube system is functioning properly. the client is developing subcutaneous emphysema.

the chest tube system is functioning properly. Fluctuation of fluid with respirations in the water seal column 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 bubbling occurs in the water seal column.

A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client's blood glucose level in the emergency care unit was 576 mg/dl (31.97 mmol/L). The physician orders an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin. The nurse piggybacks the insulin infusion into the normal saline solution. The nurse questions whether piggybacking the levofloxacin into the same I.V. line is appropriate. Which health team member should the nurse collaborate with to check the compatibility of these solutions? the physician who ordered the medications the coworker with 20 years of nursing experience the pharmacist covering the floor the infectious disease nurse

the pharmacist covering the floor

A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis? risk for activity intolerance altered health maintenance impaired physical mobility risk for fluid volume deficit

risk for activity intolerance These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.