Respiratory Disorders

A client with acute respiratory failure has just been admitted to the acute care unit. The nurse will prepare to administer which treatment(s) to the client? Select all that apply. 1. Supplemental oxygen 2. An analgesic 3. A bronchodilator 4. An antibiotic 5. A steroid

1, 2, 3, 5. Key treatments for a client with acute respiratory failure include supplemental oxygen, an analgesic such as morphine, an antianxiety agent, a bronchodilator such as albuterol, and a steroid such as hydrocortisone. Antibiotics are not necessarily needed for this client.

A client is admitted with chronic obstructive pulmonary disease (COPD). Which action(s) will the nurse perform for this client? Select all that apply. 1. Maintain an adequate airway. 2. Educate on smoking and other triggers. 3. Teach the pursed-lips breathing technique. 4. Decrease the calories in the diet. 5. Assess pulse oximetry.

1, 2, 3, 5. Typical findings for clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usually tachypneic with a prolonged expiratory phase. it is important for the nurse to maintain an adequate airway and breathing pattern for this client as well as to educate the client on the importance of avoiding any triggers that increase mucus production, such as smoking. The pursed lips breathing technique helps the client in expelling carbon dioxide; because these clients expend many calories, the calories in their diet should be increased and not decreased. Monitoring pulse oximetry is important to maintain a normal level of oxygen throughout the body.

A client comes to the clinic with chills, a low-grade fever, night sweats, and hemoptysis. Which intervention(s) will the nurse perform at this time? Select all that apply. 1. Encouraging airway clearance 2. Advocating adherence to treatment regimen 3. Promoting activity and nutrition 4. Prescribing medication therapy 5. Preventing transmission

1, 2, 3, 5. Typical signs and symptoms of active TB are chills, fever, night sweats, and hemoptysis. Clients with TB typically have low-grade fevers not higher than 102°F (38.9°C). When active TB is diagnosed it is important for the nurse to help promote airway clearance, advocate for adherence to treatment regimen, promote the importance of good nutrition and activity, and instruct the client in ways to prevent transmission. The primary healthcare provider, not the nurse, should prescribe the necessary medications.

A client has been admitted with an exacerbation of emphysema. Which classification of medication(s) will the nurse expect to administer? Select all that apply. 1. Antibiotics 2. Bronchodilators 3. Steroids 4. Diuretics 5. Calcium channel blockers

1, 2, 3. Key treatments for the client with emphysema in regard to medications include antibiotics to treat the causative agent, bronchodilators to assist in ventilation, and steroids to decrease inflammation. Diuretics and calcium channel blockers are not prescribed unless there is an underlying problem.

The nurse is caring for a client receiving oxygen via a nasal cannula at a rate of 2 L/minute. How will the nurse facilitate breathing in this client? Select all that apply. 1. Position client in Fowler's position. 2. Decrease anxiety in the client. 3. Set the line marked "2" so it cuts the ball in half. 4. Set any part of the ball so it touches the line marked "2". 5. Give the client an extra dose of a narcotic to allow for rest.

1, 2, 3. Positioning client in Fowler's position would allow for maximum chest expansion, which eases respirations. Decreasing anxiety in the client would also ease the respiratory effort. The oxygen flow rate is set by centering the indicator on the line marked "2". Having any part of the ball touching the line marked "2" is not the correct dose; giving a client an extra dose of narcotic is not safe and is considered to be a medication error.

The nurse is caring for a client diagnosed with a pulmonary embolism prescribed a ventilation-perfusion (VQ) scan. The client asks what this test can show. Which use(s) does the nurse correctly identify for this test to the client? Select all that apply. 1. To detect poor blood flow in the lungs and blood vessels 2. To examine the lungs before different types of surgeries 3. To detect air trapping in the lungs 4. To determine the location and size of the pulmonary embolism 5. To determine the location of all the peripheral arteries

1, 2, 3. The ventilation-perfusion (VQ) scan provides information on the extent of the occlusion caused by the pulmonary embolism and the amount of lung tissue involved in the area not perfused. It does not tell the size of the pulmonary embolism or the location of all the peripheral arteries. There are other reasons for doing this test: to detect poor blood flow, to detect air trapping, and to examine the lungs before different surgeries.

The nurse is caring for a client experiencing acute exacerbation of asthma. Which symptom(s) will the nurse expect to assess? Select all that apply. 1. Wheezing 2. Tachycardia 3. Hoarseness 4. Agitation 5. Chest tightness 6. Dyspnea

1, 2, 4, 5, 6. Asthma exacerbations are episodes characterized by progressive increasing in one or more typical asthma symptoms accompanied by a decrease in expiratory flow. Typical symptoms include wheezing, tachycardia, agitation, dyspnea, and chest tightness, but not hoarseness.

A client comes to the clinic and is diagnosed with active tuberculosis (TB). Which medication(s) does the nurse expect the healthcare provider to prescribe initially for this client? Select all that apply. 1. Isoniazid 2. Ethambutol 3. Clindamycin 4. Rifampin 5. Pyrazinamide

1, 2, 4, 5. The TB bacillus is airborne and carried in droplets exhaled by an infected person. Key treatments include the antitubercular medications isoniazid, ethambutol, rifampin, and pyrazinamide. Clindamycin is an antibiotic used to treat acne and other infections but not TB.

A client has been diagnosed with cor pulmonale. Which test result(s) will the nurse expect to see in this client? Select all that apply. 1. Large central pulmonary arteries upon x-ray 2. Increased right pulmonary artery pressure 3. Decreased pulmonary vascular resistance 4. Decreased right ventricular pressure 5. Increased pulmonary vascular resistance

1, 2, 5. An arterial blood gas analysis in a client with cor pulmonale would exhibit decreased PaO₂. Chest x-ray would show large central pulmonary arteries and suggest right ventricular enlargement by rightward enlargement of cardiac silhouette. Pulmonary artery pressure measurements would show increased right ventricular and pulmonary artery pressures because of the increased pulmonary vascular resistance.

A client who has chronic bronchitis asks the nurse to identify things that will help to promote better oxygenation. Which lifestyle factor(s) will the nurse identify as affecting the client's oxygenation? Select all that apply. 1. Nutrition 2. Physical exercise 3. Ethnicity 4. Genetics 5. Anxiety

1, 2, 5. Lifestyle factors that affect oxygenation are nutrition, physical exercise, smoking, substance abuse, and anxiety. Other factors may affect a client's oxygenation as well. Ethnicity and genetics are not lifestyle factors.

A client is admitted to the acute care unit due to a chronic cough with copious, foul-smelling secretions. The nurse identifies dyspnea, hemoptysis, and recent weight loss. What is the priority action(s) by the nurse for this client? Select all that apply. 1. Monitor respiratory status. 2. Check oxygen saturation levels. 3. Provide supportive care. 4. Give intravenous penicillin. 5. Administer albuterol.

1, 2. The client most likely has bronchiectasis. The priority intervention would be to monitor respiratory status and pulse oximetry. Providing supportive care is also important, but not as important as monitoring values to ensure adequate oxygenation. Antibiotics and bronchodilators are part of the overall treatment but are not priority.

The nurse is caring for a client scheduled for a bronchoscopy. Which intervention(S) will the nurse perform to prepare the client for this procedure? Select all that apply. 1. Explain the procedure. 2. Withhold food and fluids for 2 hours before the test. 3. Provide a clear liquid diet for 6 to 12 hours before the test. 4. Confirm a signed informed consent form has been obtained. 5. Ask the client to remove dentures. 6. Administer a sedative as prescribed.

1, 4, 5, 6. All procedures must be explained to the client to obtain informed consent and to reduce anxiety. A signed informed consent form is required for all invasive procedures. Dentures need to be removed for bronchoscopy because they may become dislodged during the procedure. A sedative, such as lorazepam, midazolam, or diazepam, is given to relax the client. Food and fluids are restricted for 6 to 12 hours before the test to avoid the risk of aspiration during the procedure.

Which intervention will the nurse complete before a client's chest tube is removed? 1. Provide the results of the most recent chest x-ray for the healthcare provider. 2. Ensure the healthcare provider prescribes arterial blood gas analysis before removal. 3. Disconnect the drainage system from the chest tube before removal. 4. Sedate the client to limit the amount of discomfort the client will experience.

1. A chest x-ray should be done before chest tube removal to ensure the client's lung has remained expanded after suction was discontinued. Pulse oximetry would be sufficient and is more commonly used than arterial blood gas analysis to tract oxygenation. Disconnecting the drainage system before the chest tube is removed could cause a tension pneumothorax. Client cooperation during chest tube removal is desirable; if the client can hold his or her breath while the chest tube is removed, there is less chance that air will be drawn back into the pleural space during removal. Therefore, the client should not be sedated.

A client with a pulmonary embolism has received a thrombolytic medication. What is the most important concept for the nurse to educate this client and family on at this time? 1. The medication was given to break apart the blood clot blocking the pulmonary artery 2. The medication is taken orally and will thin the blood 3. The medication will prevent future clots from forming 4. The medication will help the client to breathe by dilating bronchial tubes

1. A thrombolytic medication is given IV to break apart or dissolve blood clots. It is not given orally, does not prevent future clots from forming and has no effect on the bronchial tubes.

A client diagnosed with a pulmonary embolism is having chest pain and apprehension. Which nursing intervention is appropriate for this client? 1. Administering analgesics 2. Using guided imagery 3. Positioning the client on the left side 4. Providing emotional support

1. After the pulmonary embolism has been diagnosed and the amount of hypoxia determined, chest pain and the accompanying apprehension can be treated with analgesics. The nurse must monitor respiratory status frequently. Guided imagery and providing emotional support can be used as alternatives. Positioning the client on the left side when a pulmonary embolism is suspected may prevent a clot that has extended through the capillaries and into the pulmonary veins from breaking off and traveling through the heart into the arterial circulation, leading to a massive stroke.

The nurse provides education for a pregnant woman who is scheduled for a cesarean birth regarding prevention of complications that can develop after the birth. Which statement by the client indicates a need for further education? 1. "At least one complication I do not have to worry about is blood clots." 2. "I will be sure to drink plenty of fluids so my milk will come in." 3. "I will cough and take deep breaths so I do not develop pneumonia." 4. "I will need to be active as soon as possible so I do not get muscle atrophy."

1. Although venous thrombi in the thigh and pelvis are the most common sources for pulmonary emboli, clients who have undergone a cesarean birth are prone to develop clots in the amniotic fluid, leading to pulmonary embolus and possible death. Increasing fluids, coughing, and deep breathing—as well as being active—are all components that would help to prevent complications following a cesarean birth.

A client underwent an open cholecystectomy. Which complication will the nurse monitor the client for over the next 24 hours? 1. Atelectasis 2. Bronchitis 3. Pneumonia 4. Pneumothorax

1. Atelectasis develops when there is interference with the normal negative pressure that promotes lung expansion. Clients in the postoperative phase typically guard their breathing because of pain and positioning, which causes hypoxia. It is uncommon for any of the other respiratory disorders to develop after surgery.

A client arrives in the clinic reporting right-sided chest pain and shortness of breath that started suddenly. Which intervention will the nurse complete first? 1. Auscultation of breath sounds 2. A chest x-ray 3. An echocardiogram 4. An electrocardiogram

1. Auscultation of the lungs would indicate whether the breath sounds are normal or abnormal and thus help determine the cause of the shortness of breath. Depending on the results of auscultation and on the cause of the shortness of breath, the client may need a chest x-ray and an electrocardiogram. An echocardiogram may be necessary if a pulmonary embolus is suspected.

During admission, the nurse is auscultating the chest of a client with pneumonia and notes bronchial sounds. Which nursing action is most appropriate? 1. Continue to assess the client. 2. Obtain a sputum culture. 3. Notify the healthcare provider. 4. Apply oxygen via a facemask.

1. Chest auscultation reveals bronchial breath sounds over areas of consolidation, which is expected in a client with pneumonia. The nurse would continue to assess the client to determine appropriate interventions and obtain baseline data. A sputum culture will be used to determine the causative agent, but the culture is not priority over completing the initial respiratory assessment. The nurse would not notify the healthcare provider for an expected finding. There are no indications oxygen is needed at this time.

A client has been treated with antiobiotic therapy for right lower lobe pneumonia for 10 days and will be discharged today. Which finding will the nurse report to the primary healthcare provider immediately? 1. Continued dyspnea 2. Temperature of 99°F (37.2°C) 3. Respiratory rate of 20 breaths/minute 4. Vesicular breath sounds in right base

1. Continued dyspnea indicates the client is still having difficulty breathing and should be assessed by the healthcare provider before being discharged. The client's temperature is slightly elevated; however, dyspnea is most concerning. The client's respiratory rate is within normal range. If the client still had pneumonia, the breath sounds in the right base would be bronchial, not the normal vesicular breath sounds.

A client who has just had a right arthroscopy is back on the acute care unit. What action does the nurse identify as best to prevent a pulmonary embolism in this client? 1. Early ambulation 2. Frequent chest x-rays 3. Frequent lower extremity venous scans 4. Intubation of the client

1. Early ambulation helps reduce pooling of blood, which reduces the tendency of the blood to form a clot that could then dislodge. None of the other measures would prevent a pulmonary embolism from forming.

A client with chronic bronchitis asks the nurse, "Why is it important for me to exercise?" Which nursing response is best? 1. "It enhances cardiovascular fitness." 2. "It improves respiratory muscle strength." 3. "It reduces the number of acute attacks." 4. "It worsens respiratory function and is discouraged."

1. Exercise can improve cardiovascular fitness which helps the client to better tolerate periods of hypoxia, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients cannot tolerate the type of exercise necessary to do this. Exercise will not reduce the number of acute attacks. In some instances, exercise may be contraindicated. The client should check with the healthcare provider before starting any exercise program.

The nurse is caring for an older adult client newly diagnosed with pneumonia. Which symptoms will the nurse monitor this client for first? 1. Altered mental status and dehydration 2. Fever and chills 3. Hemoptysis and dyspnea 4. Pleuritic chest pain and cough

1. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but older adult clients are more likely to first exhibit only an altered mental status and dehydration due to a blunted immune response.

A client is suspected of impending anaphylaxis secondary to a hypersensitivity to a medication. Which nursing action is priority? 1. Administer oxygen. 2. Insert an IV catheter. 3. Obtain a complete blood count (CBC). 4. Take vital signs.

1. Giving oxygen would be the best first action in this case. Vital signs then should be checked and the healthcare provider immediately notified. If the client does not already have an IV catheter, one may be inserted now if anaphylactic shock is developing. Obtaining a CBC would not help the emergency situation.

The client who has a pulmonary embolus is also experiencing hemoptysis. When educating the client, what is the nurse's best explanation for the cause of hemoptysis? 1. Alveolar damage in the infarcted area 2. Involvement of major blood vessels in the occluded area 3. Loss of lung parenchyma 4. Loss of massive lung tissue

1. Infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in large amounts. There is a loss of lung parenchyma and subsequent scar tissue formation, and blood vessels may be involved, but these do not cause hemoptysis.

Which prescription will the nurse expect for a client who recently had a central venous access device inserted and is now short of breath and anxious? 1. Chest x-ray 2. Electrocardiogram 3. Laboratory tests 4. Sedation

1. Inserting an IV catheter in the subclavian vein can result in a pneumothorax, so a chest x-ray should be done. If it is negative, then other tests should be done, but they are not appropriate as the first intervention.

An adult client who is being treated in the emergency department with a diagnosis of status asthmaticus is prescribed albuterol and intravenous (IV) prednisone. Which finding indicates to the nurse the client's treatment was not effective? 1. The client's lips have a bluish tint. 2. The client's legs are shaking. 3. The client's heart rate is 120 beats/minute. 4. The client reports flushing of the face.

1. Lips with a bluish tint are a sign of respiratory distress indicating ineffective treatment. Shaking of the extremities is a common side effect of albuterol. A rapid heart rate is a common side effect of both albuterol and IV prednisone. Flushing is a common side effect of IV prednisone. These side effects do not indicate treatment was not effective.

The nurse is monitoring the progress of a client with acute respiratory distress syndrome (ARDS). Which finding best indicates to the nurse the client's condition is improving? 1. Arterial blood gas (ABG) values are normal 2. The bronchoscopy results are negative 3. The client's blood pressure has stabilized 4. The sputum and sensitivity culture shows no growth in bacteria

1. Normal ABG values would indicate that the client's oxygenation has improved. ARDS is characterized by hypoxia, so the bronchoscopy and sputum culture results have no bearing on the improvement of ARDS. Improved blood pressure is not relative to the client's respiratory condition.

What is the priority nursing intervention when caring for a client with a pulmonary embolism? 1. Assessing oxygenation status 2. Monitoring the oxygen delivery device 3. Monitoring for other sources of clots 4. Determining if the client needs a ventilation-perfusion (VQ) scan

1. Nursing management of a client with a pulmonary embolism focuses on assessing oxygenation status and ensuring treatment is adequate. If the client's status begins to deteriorate, it is the nurse's responsibility to contact the healthcare provider and attempt to improve oxygenation. Monitoring for other clot sources, determining if a test is appropriate for the client, and ensuring the oxygen delivery device is working properly are other nursing responsibilities, but they are not the focus of care.

Which intervention requires the nurse to frequently monitor a client with chronic obstructive pulmonary disease (COPD)? 1. Administering opioids for pain relief 2. Increasing the client's fluid intake 3. Monitoring the client's cardiac rhythm 4. Assisting the client with coughing and deep breathing

1. Opioids suppress the respiratory center in the medulla. Both COPD and pneumonia cause alterations in gas exchange; any further problems with oxygenation could result in respiratory failure and cardiac arrest. Increasing the fluid intake would help to thin the client's secretions. Although the nurse would need to monitor the intake and output and watch for signs of heart failure, this is not as critical as administering opioids. The cardiac rhythm provides an indication of the client's myocardial oxygenation; it should be a part of the nurse's regular assessment. Assisting the client in coughing and with deep breathing should be included in the plan of care. The only caution would be to assess for possible rupture of emphysematous alveolar sacs and pneumothorax.

When monitoring the closed-chest drainage system of a client who has just returned from a lobectomy, what will the nurse be sure is occurring? 1. The fluid in the water seal chamber rises from inspiration and falls with expiration 2. The tubing remains looped below the level of the bed 3. The drainage chamber does not drain more than 100 mL in 8 hours 4. The suction-control chamber bubbles vigorously when connected to suction

1. Rise and fall of the water seal chamber immediately after surgery indicates patency of the chest tube drainage system. The tubing should be coiled on the bed, without dependent loops, to promote drainage. Up to 500 mL of drainage can occur in the first 24 hours after surgery. Gentle, not vigorous, bubbling is indicated after surgery to prevent excessive evaporation.

A client was infected with tuberculosis (TB) bacillus 10 years ago but never developed the disease. The client is now being treated for cancer and begins to develop signs of TB. Which statement by the nurse is most accurate? 1. "Some people carry dormant TB infections that develop into active disease." 2. "You should be all right since it has been 10 years since you were infected." 3. "There is a really good chance that you will now develop a superinfection." 4. "It is not unusual to develop another infection when you have cancer."

1. Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain latent for years and then activate when the client's resistance is lowered, as when a client is being treated for cancer. The nurse should not tell the client that he will be all right. Superinfection does not apply in this case. This is not a usual development for a client who has cancer.

The nurse is preparing to educate a client who has recently been diagnosed with squamous cell carcinoma of the left lung. Which statement by the nurse is best? 1. "You have a slow-growing cancer that rarely spreads." 2. "In terms of prognosis, you may have only a few months to live." 3. "Squamous cell cancer is a very rapid-growing cancer." 4. "The cancer has generally metastasized by the time the diagnosis is made."

1. Squamous cell carcinoma of the lung is a slow-growing rarely metastasizing type of cancer. It has the best prognosis of all lung cancer types.

An older adult client with pneumonia has copious secretions but is having difficulty coughing them up. Which nursing action is most appropriate? 1. Monitor the client's need for suctioning every hour. 2. Encourage the client to cough every 10 minutes. 3. Teach the client how to use an incentive spirometer. 4. Notify the client's primary healthcare provider.

1. Suctioning should be performed only when necessary, based on the client's condition at the time of assessment. Suctioning is a nursing procedure and does not require a healthcare provider's prescription. It is not appropriate to ask the client to cough every 10 minutes. Incentive spirometry would not help move the secretions.

On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse notes the client is receiving oxygen at 4 L/minute via nasal cannula. Which action will the nurse complete? 1. Decrease the oxygen flow rate. 2. Monitor the oxygen saturation level. 3. Ask whether the client uses oxygen at home. 4. Remove the nasal cannula and apply a face mask.

1. The administration of oxygen at 1 to 2 L/minute by way of nasal cannula is recommended for clients with COPD; therefore a rate of 4 L/minute is too high. The normal mechanism that stimulates breathing is a rise in blood carbon dioxide. Clients with COPD retain blood carbon dioxide, so their mechanism for stimulating breathing is a low blood oxygen level. High levels of oxygen may cause hypoventilation and apnea. Oxygen delivered at 1 to 2 L/minute should aid in oxygenation without causing hypoventilation. Whether the client uses oxygen at home has no bearing on the priority nursing action in this situation. The nurse should monitor the oxygen saturation level after correcting the flow rate. It is not appropriate to switch the client to a face mask.

A client is experiencing a new-onset asthma attack. Which position will the nurse immediate place the client in? 1. High Fowler's 2. Left side-lying 3. Right side-lying 4. Supine

1. The best position is high Fowler's, which helps lower the diaphragm and facilitates passive breathing and thereby improves air exchange. A side-lying position would not facilitate the client's breathing. A supine position increases the breathing difficulty of a client with asthma.

A client is receiving emergency care following a motor vehicle accident. The nurse notes absent breath sounds over the left lung field, shortness of breath, and tachypnea. Which primary healthcare provider prescription will the nurse question? 1. Prepare client for intubation. 2. Gather chest tube insertion equipment. 3. Aminister oxygen. 4. Apply a continuous oxygen saturation monitor.

1. The nurse would suspect the client has a left pneumothorax. A pneumothorax can occur as a result of trauma in which the pleurae separating the lung from the chest wall are damaged, allowing air to enter the pleural space. This air causes the lung to collapse, resulting in absent breath sounds. Treatment includes a chest tube, oxygen, and continuous monitoring. The client does not require intubation at this time.

A client with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). Which action will the nurse take first? 1. Place the client on airborne precautions. 2. Administer isoniazid and have the client rest. 3. Give a tuberculin skin test. 4. Assess for adventitious breath sounds.

1. This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. The client should be placed on airborne precautions immediately, and three sputum cultures should be obtained to confirm the diagnosis. The client would then most likely be given isoniazid and two or three other antitubercular antibiotics until the diagnosis is confirmed, and then isolation and treatment would continue if the cultures were positive for TB. The client does not need a skin test. The nurse should perform a respiratory assessment after placing the client on isolation.

The right forearm of a client who had purified protein derivative (PPD) test for tuberculosis (TB) is reddened and raised about 3 mm where the test was given. What will the nurse do next? 1. Document the findings. 2. Place the client on isolation. 3. Check to see if client had an x-ray 4. Notify the healthcare provider.

1. This test would be classed as negative; therefore, the nurse would document the findings and continue to monitor the client. A 3 mm raised area would be a positive result if a client had recent close contact with someone diagnosed with, or suspected of having, infectious TB. The remaining options are not appropriate for this client.

A client who was hospitalized for pulmonary embolism is being discharged on warfarin therapy. Which statement by the nurse about warfarin therapy is appropriate? 1. "Warfarin therapy inhibits the formation of blood clots." 2. "It is given to continue to reduce the size of the pulmonary embolism." 3. "It will reduce blood pressure and prevent venous stasis." 4. "Coagulation studies to monitor bleeding times will be necessary every 6 months."

1. Warfarin inhibits clot formation by interfering with clotting factors that are dependent on vitamin K. Warfarin does not dissolve clots and will not reduce the size of the pulmonary embolus. It does not reduce blood pressure and will not prevent venous stasis. Coagulation studies would be performed every 2 to 4 weeks while the client is receiving warfarin.

The nurse is assessing a client with smoke inhalation. When auscultating the lungs, which breath sound(s) will the nurse expect to hear? Select all that apply. 1. Crackles 2. Diminished breath sounds 3. Inspiratory and expiratory wheezing 4. Upper airway rhonchi 5. Stridor

1. When treating smoke inhalation, the most frequently heard sounds are crackles throughout the lung fields. Decreased breath sounds or inspiratory and expiratory wheezing are associated with asthma, and rhonchi are heard when there is sputum in the airways. Stridor indicates upper airway obstruction.

The nurse is caring for a client who begins experiencing status asthmaticus. Which medication does the nurse prepare to administer this client? 1. Inhaled levalbuterol 2. Inhaled fluticasone 3. Intravenous albuterol 4. Oral prednisone

1. Inhaled beta-adrenergic agents, such as levalbuterol, help promote bronchodilation, which improves oxygenation. IV beta-adrenergic agents, such as albuterol, can be used but have to be monitored because of their greater systemic effects. They are typically used when the inhaled beta-adrenergic agents do not work. Corticosteroids, such as fluticasone and prednisone, are slow-acting, so their use will not reduce hypoxia in the acute phase.

What is the rationale(s) for the nurse providing preoperative education for a client who will be undergoing lung surgery? Select all that apply. 1. Deciding whether the client should have surgery 2. Offering emotional support 3. Giving detailed explanations of the surgery 4. Providing general information 5. Answering questions

2, 4, 5. The nurse's role is to provide general, not detailed, information about the client's surgery, explain preoperative and postoperative care, answer the client's questions, and offer emotional support. The nurse's role is not to decide whether the client should have surgery. If the client has questions that require detailed explanations of the surgery, the client should be referred to the surgeon.

The nurse is caring for a client exhibiting signs of impending anaphylaxis from a medication hypersensitivity. The client has a history of asthma. Which action by the nurse is priority? 1. Give a beta-blocker. 2. Administer albuterol. 3. Obtain serum electrolyte levels. 4. Lay the client flat in the bed.

2. A bronchodilator, such as albuterol, would help open the client's airway and improve oxygenation status. Beta-blockers are not indicated in the management of asthma because they may cause bronchospasm. Obtaining laboratory values would not be done on an emergency basis, and having the client lie flat in bed could worsen the client's ability to breathe.

The nurse is reviewing data on a client suspected of having a pneumothorax. Which intervention will the nurse use to confirm the diagnosis? 1. Auscultation of breath sounds 2. Review of chest x-ray results 3. Incentive spirometer use 4. Assessment of the client for signs of dyspnea

2. A chest x-ray would show the area of collapsed lung if pneumothorax is present, as well as the volume of air in the pleural space. Listening to breath sounds would not confirm a diagnosis. The client would not do well with an incentive spirometer at this time. A client may experience dyspnea for many reasons besides a pneumothorax.

A client who is a longtime smoker receives lab results that indicate an elevated carcinoembryonic antigen level. Which action will the nurse take in response to these results? 1. Inform the client it means lung cancer is definitely present. 2. No action is needed; this level is usually elevated in a smoker. 3. Inform the client cancer is present and has now spread to other organs. 4. Inform the client death is imminent due to some cancer in the body.

2. Because the level of carcinoembryonic antigen is elevated in clients who smoke, it cannot be used as a general indicator of cancer. This test by itself cannot confirm cancer of any kind in a smoker. However, the carcinoembryonic antigen level is helpful in monitoring cancer treatment because it usually falls to normal within 1 month if treatment is successful.

The nurse is assigned to care for a client with a chest tube and observes constant bubbling in the water seal chamber of the closed drainage system. Which nursing action will be performed first? 1. Document the finding in the medical record. 2. Check the system's connections. 3. Continue to monitor the client. 4. Perform a comprehensive pulmonary assessment.

2. Constant bubbling in the water seal chamber indicates a leak or loose connection between the client and the water seal chamber. The nurse would assess the system first. The nurse will document the findings, continue monitoring the client, and perform pulmonary assessments after determining the cause of the bubbling.

A client with a long history of smoking is suspected of having lung cancer. The nurse knows which intervention is most important at this point to increase the client's chances of survival, should the client prove to have lung cancer? 1. Bronchoscopy, with hopes of early detection 2. Chest x-ray, with hopes of early detection 3. High-dose chemotherapy, should the client be shown to have cancer 4. Smoking cessation, should the client be shown to have cancer

2. Detecting cancer early when the cells may be premalignant and potentially curable would be most beneficial. However, a tumor must be 1 cm in diameter before it is detectable on a chest x-ray, so this is difficult. If the cancer is detected early, a bronchoscopy may help identify cell type. High-dose chemotherapy has minimal effect on long-term survival. Smoking cessation will not reverse the process but may prevent further decompensation.

Which data will the nurse gather immediately to determine the status of a client with a respiratory rate of 4 breaths/minute? 1. Arterial blood gas (ABG) levels and breath sounds 2. Level of consciousness (LOC) and a pulse oximetry value 3. Breath sounds and reflexes 4. Pulse oximetry value and heart sounds

2. First, the nurse should attempt to rouse the client because this should increase the client's respiratory rate. Then a spot pulse oximetry check should be done and breath sounds should be checked. The healthcare provider should be notified immediately of the findings and is likely to prescribe an ABG to determine specific carbon dioxide and oxygen levels. Heart sounds and reflexes should be checked after these initial actions are completed.

Following a pulmonary embolism, a client is placed on IV heparin. The client asks the nurse about the purpose of the heparin. Which statement by the nurse is appropriate? 1. "Heparin will dissolve the clot in your lungs." 2. "Heparin will slow the development of any more clots." 3. "Heparin will prevent pieces of the clot from breaking off and going to your lung." 4. "Heparin will dissolve any circulating clots."

2. Heparin is an anticoagulant and is administered to slow thrombus formation. Fibrinolytic medications dissolve clots. Heparin will not prevent clots from embolizing or dissolve circulating clots.

An unconscious client has been diagnosed with a probably drug overdose complicated by alcohol ingestion. What is the priority nursing intervention? 1. Administer IV fluids. 2. Give IV naloxone. 3. Monitor vital signs. 4. Draw blood for a drug screen.

2. If the client took opioids, giving naloxone could reverse the effects and awaken the client. IV fluids would then most likely be administered, and the nurse would closely monitor the client over a period of several hours to several days. A drug screen should be drawn in the emergency department, but results may not come back for several hours, making it of lower priority than administering the naloxone.

The emergency room nurse will assess which client first? 1. A 20-year-old client in moderate pain due to probably appendicitis 2. A 32-year-old client thrown from the car during a motor vehicle accident 3. A 40-year-old client reporting nasal congestion for 2 weeks 4. A 55-year-old who has pneumonia and an unproductive cough

2. In a client with massive trauma, the tissues lining the alveoli and pulmonary capillaries are injured directly or indirectly, increasing the permeability of protein and fluid and leading to the development of hypoxemia and ARDS, making this client the most emergent and in need of assessment. A client with appendicitis, unless it causes overwhelming sepsis, is not as emergent as one with massive trauma and impending ARDS. Pneumonia and nasal congestion are not emergent in this situation.

The nurse is caring for a client with a fat embolism after a fractured femur. Following respiratory therapy, the client continues to be hypoxic. What is the best intervention by the nurse? 1. Administer furosemide. 2. Give neuromuscular blockers. 3. Place the head of the bed flat. 4. Provide albuterol.

2. Neuromuscular blockers cause skeletal muscle paralysis, reducing the amount of oxygen used by the restless skeletal muscles. This should improve oxygenation. Bronchodilators may be used, but they typically do not have enough of an effect to reduce the amount of hypoxia present. The head of the bed should be partially elevated to facilitate diaphragm movement, and diuretics can be administered to reduce pulmonary congestion. However, bronchodilators, diuretics, and head elevation would improve oxygen delivery, not reduce oxygen demand.

The nurse has advised a client's family not to increase the client's oxygen flow rate. Which rationale is most appropriate for the nurse to provide the family? 1. Extra oxygen may cause the client to breathe too rapidly 2. Oxygen toxicity may reduce the amount of functional alveolar surface area 3. Increased oxygen may decrease carbon dioxide levels and cause apnea 4. Increasing the oxygen level may cause pulmonary barotrauma

2. Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake. Excessive oxygen therapy may eliminate hypoxic respiratory drive, causing the client to breathe too slowly or even to stop breathing. Pulmonary barotrauma is caused by high lung pressures, not excessive oxygenation.

A client diagnosed with pleural effusion has been on supplemental oxygen for 24 hours and is still having dyspnea with decreased breath sounds on the left side of the chest. The nurse will anticipate preparing the client for which procedure? 1. Thoracotomy 2. Thoracentesis 3. CT scan 4. Bronchoscopy

2. Pleural fluid normally seeps continually into the pleural space from the capillaries, lining the parietal pleura; the fluid is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid leads to a pleural effusion. Key treatments include supplemental oxygen and a thoracentesis to remove the fluid. If this is not successful, then a thoracotomy is performed. The client is also placed on antibiotics to treat the organism that causes empyema. A CT scan and bronchoscopy are not indicated for this client and would not address the client's dyspnea.

A client who has chronic obstructive bronchitis is prescribed furosemide. Which explanation will the nurse give the client regarding the beneficial effects of taking this medication? 1. Furosemide helps improve the clients' mobility 2. Furosemide helps reduce oxygen demand 3. Furosemide helps reduce sputum production 4. Furosemide helps improve respiratory function

2. Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand, and in turn, reduces the respiratory rate. Sputum may get thicker and make it harder to clear airways. Reducing fluid volume will not improve respiratory function but may improve oxygenation. Reducing fluid volume may reduce edema and improve mobility slightly, but exercise tolerance would still be poor.

A client who has being treated for pneumonia has a persistent cough and reports severe pain on coughing. Which instruction will the nurse provide to the client? 1. "You need to hold in your cough as much as possible." 2. "Splint your chest wall with a pillow when you cough." 3. "Place the head of your bed flat to help with coughing." 4. "Restrict fluids to help decrease the amount of sputum."

2. Showing this client how to splint the chest wall should help decrease discomfort when coughing. Holding in coughs would only increase pain. Placing the head of the bed flat may increase the frequency of coughing and require more respiratory effort; a 45-degree angle may help the client cough more efficiently and with less pain. Increasing fluid intake would help thin secretions, making it easier for the client to clear them. Promoting fluid intake is appropriate in this situation.

A client with pneumonia has a nonproductive cough and copious secretions. Which action will the nurse encourage the client to perform to facilitate effective coughing? 1. Lying in semi-Fowler's position 2. Sipping water, hot tea, or coffee 3. Inhaling and exhaling from pursed lips 4. Using thoracic breathing

2. Sips of water, hot tea, or coffee may stimulate coughing. The best position is sitting in a chair with the knees flexed and feet placed firmly on the floor. The client should inhale through the nose and exhale through pursed lips. Diaphragmatic, not thoracic, breathing helps to facilitate coughing.

An adolescent client comes to the emergency department with acute asthma. The nurse notes a respiratory rate of 44 breaths/minute and severe respiratory distress. What is the priority nursing action? 1. Take a full medical history. 2. Give a bronchodilator by nebulizer. 3. Apply an apneic monitor to the client. 4. Provide emotional support to the client.

2. The client having an acute asthma attack needs to increase oxygen delivery to the lungs and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. The priority at this time is the respiratory status, and the client with be anxious until this is resolved. First, resolve the acute phase of the attack; afterward, obtain a full medical history to determine the cause of the attack and how to prevent attacks in the future. Application of an apneic monitor is not a priority at this point in the treatment plan.

A client diagnosed with active tuberculosis (TB) asks the nurse, "Why do I have to be hospitalized?" Which nursing response is most appropriate? 1. "To evaluate the severity of your current condition." 2. "To prevent you from spreading of the disease to others." 3. "To determine whether you will be compliant with treatment." 2. "To determine which antibiotic therapy will work best for you."

2. The client with active TB is highly contagious until three consecutive sputum cultures are negative, so the client is put on airborne precautions in the hospital. Assessment of the client's physical condition, need for antibiotic therapy, and likely compliance are not considered primary reasons for hospitalization in this case.

What is the primary intervention by the nurse while caring for a client with terminal lung cancer? 1. Offering emotional support 2. Ensuring pain control 3. Providing nutritional support 4. Preparing the client's will

2. The client with terminal lung cancer may have extreme pleuritic pain and should be treated to reduce discomfort. Preparing the client and family for the impending death is also important but should not be the primary focus until pain is under control. Nutritional support may be provided, but as the terminal phase advances, the client's nutrition needs greatly decrease. Nursing care does not focus on helping the client prepare a will.

A client with lung cancer is experiencing excruciating pain due to the size of the tumor and is scheduled for a lung resection the next morning. What education will the nurse provide regarding lung resection? 1. The surgery will remove the tumor and all surrounding tissue 2. The surgery will remove the tumor and as little surrounding tissue as possible 3. A biopsy of the tumor will be done as well as removal of the whole tumor 4. A biopsy of the tumor will be done and half of the tumor will be removed

2. The goal of surgical lung resection is to remove the cancerous lung tissue that has tumor in it while preserving as much surrounding tissue as possible. It may be necessary to remove alveoli and bronchioles, but care is taken to remove only what is absolutely necessary.

A client requires a chest tube to be inserted in the right upper chest. Which action will the nurse perform during the procedure? 1. Injecting local anesthetic to prevent pain 2. Preparing the chest tube drainage system 3. Bringing the chest x-ray to the client's room 4. Inserting the chest tube

2. The nurse must anticipate a drainage system is required and assemble it before the insertion, so the tube can be directly connected to the drainage system. The chest x-ray does not need to be brought to the client's room. The healthcare provider should administer the local anesthetic and insert the chest tube.

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure? 1. Explain the procedure to the client. 2. Check all allergies of the client. 3. Watch for radioactive gas leaks. 4. Obtain the client's vital signs.

2. The priority action for the nurse is checking to see if the client has any allergies, as lung scans are contraindicated in clients that have a hypersensitivity to the radiopharmaceutical dye. After that it is important to also explain the procedure, obtain the vital signs, and during the procedure watch for any gas leaks.

A client with a benign lung tumor is scheduled for removal of the tumor. Which statement made by the client demonstrates to the nurse a proper understanding of the reason for the procedure? 1. "It will facilitate pain control." 2. "It will prevent further lung compression." 3. "It will help to prevent metastatic cancer." 4. "It is for cosmetic purposes."

2. The tumor is removed to prevent further compression of lung tissue as the tumor grows, which could lead to respiratory decompensation. If for some reason the tumor cannot be removed, then chemotherapy or radiation may be used to try to shrink it. At this point pain is not a problem; preventing cancer and cosmetics are not issues in this case.

An unconscious client who overdosed on an opioid receives naloxone. After the client awakens, what is the priority action by the nurse? 1. Feed the client with a well-balanced meal. 2. Educate on the effects of mixing opioids with alcohol. 3. Discharge the client from the hospital. 4. Admit the client to an inpatient psychiatric facility.

2. This client needs information about the dangers of combining opioids and alcohol. Discharge at this point is inappropriate. Unless the client was trying to commit suicide, admission to a psychiatric facility is not necessary. It may not be advisable to feed the client at first; the level of consciousness could drop again, increasing the possibility of aspiration.

The nurse auscultates inspiratory and expiratory wheezes with a decreased forced expiratory volume in a client with asthma. Which class of medication will the nurse administer first? 1. Beta-blockers 2. Bronchodilators 3. Inhaled steroids 4. Oral steroids

2. Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Inhaled or oral steroids may be given to reduce the inflammation but are not used for emergency relief. Beta-blockers are not used to treat asthma and can cause bronchoconstriction.

The nurse is caring for a client with pneumonia. The healthcare provider prescribes 600 mg of ceftriaxone oral suspension to be given once per day. The medication label states ceftriaxone 125 mg/5 mL. How many milliliters of medication will the nurse administer to the client? Record your answer using a whole number.

24. To calculate drug dosage, use the formula: Dose on hand / quantity on hand = Dose desired / X In this case, 125 mg / 5 mL = 600 mg / X Therefore, X = 24 mL

A client is exhibiting signs of asthma. Which finding(s) provides the nurse with confirmation of this diagnosis? Select all that apply. 1. Circumoral cyanosis 2. Increased forced expiratory volume 3. Chest tightness 4. Normal breath sounds 5. Expiratory and inspiratory wheezing

3, 5. Inspiratory and expiratory wheezes and chest tightness are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds would be "tight" sounding or markedly decreased; they would not be normal.

A client is suspected of having a pulmonary embolus. Which definitive test will the nurse prepare the client for? 1. Arterial blood gas (ABG) analysis 2. Computed tomography (CT) scan 3. Pulmonary angiogram 4. Ventilation-perfusion (VQ) scan

3. A pulmonary angiogram is used to definitively diagnose a pulmonary embolism. A catheter is passed through the circulation to the region of the occlusion; the region can be outlined with an injection of contrast medium and viewed by fluoroscopy. This shows the location of the clot, as well as the extent of the perfusion defect. A computed tomography (CT) scan can show the location of infarcted or ischemic tissue but cannot be used for a definitive diagnosis. ABG levels can define the amount of hypoxia present but cannot be used for a definitive diagnosis. The ventilation-perfusion (VQ) scan can report whether there is a ventilation-perfusion mismatch present and define the amount of tissue involved but cannot be used for a definitive diagnosis.

A client has been diagnosed with lung cancer and is told a wedge resection is required. The client appears confused and asks the nurse for an explanation. What is the nurse's best response? 1. "The healthcare provider will remove one entire lung." 2. "The lobe of the lung involved will be removed." 3. "A small, localized area near the surface of the lung will be removed." 4. "A segment of the lung, including a bronchiole and alveoli, will be removed."

3. A very small area of tissue close to the surface of the lung is removed in a wedge resection. A segment of the lung is removed in a segmental resection, a lobe is removed in a lobectomy, and an entire lung is removed in a pneumonectomy.

An older adult client has just been admitted with pneumonia. The client tells the nurse, "I have never had pneumonia before and nobody in my family has ever suffered from pneumonia. I do not understand how I contracted this disease." Which statement by the nurse is most appropriate? 1. "You should not worry about how you contracted pneumonia." 2. "You could have had it in the past and not know it." 3. "Advanced age is a risk factor for developing pneumonia." 4. "Immobility can help to prevent this disease."

3. Advanced age, due to the possibility of depressed cough and glottis reflexes and nutritional depletion, is a risk factor for developing pneumonia. Telling the client not to worry is incorrect as pneumonia can be deadly. Saying that the client might have contracted pneumonia in the past is not really helpful or therapeutic. Immobility is a risk factor and not a factor that would prevent pneumonia.

A client experiencing acute respiratory distress is lying flat in bed. When entering the room, the nurse suggests to the client a change in position would be beneficial. Which position will the nurse recommend? 1. Lying prone 2. Side-lying on the left side 3. Alternating prone and supine 4. Lying supine

3. Alternating supine and prone positioning (if possible) is recommended for clients with acute respiratory distress. Turning the client to the prone position may recruit new alveoli in the posterior region of the lung and improve oxygenation status.

A hospitalized client needs a central venous assess device inserted. The healthcare provider places the device in the subclavian vein. Shortly afterward, the client develops shortness of breath and appears restless. Which action will the nurse take first? 1. Administer a sedative. 2. Advise the client to calm down. 3. Auscultate breath sounds. 4. Start an intravenous line.

3. Because this is an acute episode, the nurse should listen to the client's lungs to see whether anything has changed. The nurse should not give this client medication, especially sedatives, because the client is having trouble breathing; the medication may further decrease respirations. The nurse should give the client emotional support and contact the healthcare provider who placed the central venous access after auscultation, but should not advise the client to calm down as this is not therapeutic. Starting an intravenous line is not indicated at this time.

The nurse working in a walk-in clinic has been alerted of an outbreak of tuberculosis (TB). Which client does the nurse identify as having the highest risk for developing TB? 1. A 16-year-old high school student 2. A 33-year-old day care worker with asthma 3. A 43-year-old who is homeless with a history of alcoholism 4. A 54-year-old business professional who travels a few times a year

3. Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a homeless client with a history of alcoholism, are at extremely high risk for developing TB. A high school student, a business professional, a day care worker have much lower risk for contracting TB, regardless of their age.

A client admitted with a diagnosis of pneumonia asks the nurse, "I heard the nurse at the clinic say I was a 'blue bloater.' What does that mean?" Which response from the nurse is best? 1. "This means you are exhaling too much oxygen." 2. "This means you are producing a lot of sputum." 3. "This means you are retaining more carbon dioxide." 4. "This means you are coughing more frequently than normal."

3. Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Retaining more carbon dioxide, not exhaling more oxygen, is the reason for the blue color. Producing more sputum and coughing more frequently do not contribute to the overall color of the client. Clients with emphysema appear pink and cachectic.

When explaining the hypoxic drive to a client with emphysema, which statement by the nurse is best? 1. "This is when your body does not notice you need to breathe." 2. "This is when you only breathe when your oxygen levels climb above a certain point." 3. "This is when you only breathe when your oxygen levels dip below a certain point." 4. "This is when you only breathe when your carbon dioxide level dips below a certain point."

3. Clients with emphysema breathe when their oxygen level drop to a certain level; this is known as the hypoxic drive. Clients with emphysema and chronic obstructive pulmonary disease take a breath when they have reached this low oxygen level. They do not take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology. If too much oxygen is give, the client has little stimulus to take another breath. The client's carbon dioxide levels climb, the client loses consciousness, and respiratory arrest occurs.

The nurse is caring for a client with a fracture of the right femur caused by a skiing accident. Which clinical manifestation will the nurse suspect is a complication of the fracture? 1. Abdominal cramping 2. Fatty stools 3. Confusion 4. Numbness in the right foot

3. Confusion and irritability are signs of hypoxia, which is caused by the fat emboli traveling to the lungs and producing an inflammatory response in the lung tissue. Abdominal cramping may be a sign of abdominal distention and constipation caused by immobility, not by the fracture itself. Fatty stools occur with pancreatitis, not secondary to fracture of the femur. Numbness may be secondary to neurovascular impairment.

Which symptom will the nurse expect to observe first in a client with an acute pulmonary embolism? 1. Distended jugular veins 2. Bradycardia 3. Dyspnea 4. Nonproductive cough

3. Dyspnea is usually the first symptom of pulmonary embolus because the thrombus prevents gas exchange in the pulmonary arterial bed. If the embolus is large enough, the client may then develop right ventricular failure, with such symptoms as distended jugular veins, tachycardia, and circulatory collapse. The client may also have hemoptysis.

When a chest tube is inadvertently dislodged from a client, what will be the nurse's first action? 1. Notify the healthcare provider. 2. Wipe the chest tube with alcohol and reinsert. 3. Apply a petroleum gauze over the site. 4. Auscultate the lung fields for breath sounds.

3. If a chest tube is unintentionally dislodged, the nurse would immediately cover the insertion site opening with petroleum gauze and apply pressure to prevent air from entering the chest and causing a tension pneumothorax. Next, notify the healthcare provider. It is not appropriate to attempt to reinsert the chest tube. Auscultation of the lungs may be important but is not the priority.

The nurse is referring a client with a positive Mantoux skin test result for a chest x-ray. The client is confused and asks the nurse why the extra radiation is necessary. Which response by the nurse is best? 1. "The x-ray is to confirm the suspected diagnosis." 2. "The x-ray is to determine whether a repeat skin test is needed." 3. "The x-ray is to determine the extent of lesions." 4. "The x-ray will show whether this is a primary or secondary infection."

3. If the lesions are large enough, the chest x-ray will show their presence in the lungs. Sputum culture, not an x-ray or additional skin test, confirms the diagnosis, as false-positive and false-negative skin test results may occur. A chest x-ray cannot determine whether this is a primary or secondary infection.

A client has symptoms of acute asthma every time the family eats at a Chinese restaurant. Which instruction will the nurse provide for this client? 1. "Only eat Chinese food once per month." 2. "Use your inhalers before eating Chinese food." 3. "Avoid Chinese food because it is a trigger for you." 4. "Next time, order different food to see if that helps."

3. If the trigger of an acute asthma attack is known, this trigger should always be avoided. Food is typically a trigger for an acute asthma attack, and using an inhaler before eating would not prevent an attack.

A client is being screened in the clinic for tuberculosis. The client reports having negative purified protein derivative (PPD) test results in the past. The nurse performs a PPD test on the client's right forearm. Which statement by the client indicates a need for further education? 1. "I need to return to the clinic to assess the results." 2. "I can return to the clinic in 48 hours for the results." 3. "I do not have to return to the clinic if the area stays flat." 4. "A healthcare provider has to read the results."

3. It is very important to have the results read accurately and clients should return to the clinic for this. PPD tests should be read in 48 to 72 hours. If read too early or too late, the results will not be accurate. The client cannot self-read the results; it is also important that a healthcare provider (physician, nurse, etc.) read the results.

A client with atelectasis is prescribed oxygen therapy. What will the nurse expect the healthcare provider to prescribe for this client? 1. Ventilation with continuous positive airway pressure (CPAP) 2. Ventilation with a nasal cannula 3. Ventilation with positive end-expiratory pressure (PEEP) 4. Ventilation with a face mask only

3. PEEP delivers positive pressure to the lung at the end of expiration. This helps open collapsed alveoli and helps them stay open so gas exchange can occur in these newly opened alveoli, improving oxygenation. CPAP, or continuous positive airway pressure, is a treatment that uses mild air pressure to keep the airways open. CPAP typically is used by people who have breathing problems such as sleep apnea. A face mask or nasal cannula would not be helpful in this situation.

The nurse is caring for a client who has a pulmonary embolism. What is the nurse's best explanation for this client's potential to develop chest pain? 1. It is the same as costochondritis 2. It is the result of a myocardial infarction 3. It is pleuritic pain due to the inflammation 4. It is caused by referred pain from the pelvis

3. Pleuritic pain is caused by the inflammatory reaction of the lung parenchyma to the pulmonary embolism. The pain is not associated with myocardial infarction, costochondritis, or referred pain from the pelvis to the chest.

A client placed on pulse oximetry monitoring asks the nurse to explain what that is. What is the best explanation by the nurse? 1. It is the amount of carbon dioxide in the blood 2. It is the amount of oxygen in the blood 3. It is the percentage of hemoglobin carrying oxygen 4. It is the respiratory rate

3. Pulse oximetry determines the percentage of hemoglobin carrying oxygen. This does not ensure that the oxygen being carried through the bloodstream is actually being taken up by the tissue. Pulse oximetry does not provide information about the amount of oxygen or carbon dioxide in the blood or the client's respiratory rate.

The nurse knows which client is at the highest risk for developing pneumonia? 1. A 45-year-old client admitted for malnutrition secondary to alcohol use disorder who smokes one pack per day 2. A 56-year-old client who is recovering from a left arthroplasty and attends physical therapy weekly 3. A 69-year-old client with chronic obstructive pulmonary disease (COPD) who lives in a group home 4. A 75-year-old client who refuses both the pneumonia and influenza vaccines has hypokalemia

3. Risk factors for the development of pneumonia include: weakened immune system, hospitalization, residing in a group living situation, chronic condition, smoking, and being older than 65 years of age. The client with advanced age, COPD, and living in a group home is at greatest risk, with three risk factors. The client admitted with malnutrition has two risk factors (hospitalization, smoker). The client who had an arthroplasty has no risk factors. The client with hypokalemia is at increased risk due to age and refusal of the vaccine.

The nurse will prepare a client who has recently been exposed to a family member diagnosed with active tuberculosis and has had several false-positive skin tests in the past for which test? 1. Chest x-ray 2. Mantoux skin test 3. Sputum culture 4. Tuberculin skin test

3. Skin tests may be false-positive for false-negative. Lesions in the lung may not be big enough to be seen on x-ray. The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis.

A client is treated in the emergency department with reports of dyspnea, cough, and sharp pain that increases with exertion. The nurse auscultates diminished breath sounds, and the healthcare provider prescribes a chest x-ray. What does the nurse suspect this will indicate? 1. Asthma 2. Pulmonary embolism 3. Spontaneous pneumothorax 4. Tuberculosis

3. Spontaneous pneumothorax is characterized by diminished or absent breath sounds with dyspnea, a cough, and tachypnea. Sharp chest pain that increases with exertion is a key sign of this condition. Asthma is usually accompanied by wheezes and produces no symptoms between attacks. Pulmonary embolism would have sudden onset of dyspnea and crackles in the lungs. TB is demonstrated by fever, night sweats, and, at times, a cough.

The nurse is caring for a client newly diagnosed with lung cancer. The primary healthcare provider is now determining the stage of the client's cancer. Which prescription(s) will the nurse question? Select all that apply. 1. Magnetic resonance imaging (MRI) 2. Computerized tomography (CT) scan 3. Obtain sputum specimen 4. Positron emission tomography (PET) scan 5. Bone scans

3. Staging describes the extent and severity of the cancer and helps the healthcare provider determine the most appropriate therapy. Staging systems continue to evolve as cancer is better understood. Multiple data collection methods, including laboratory testing, physical examination, and imaging, are used to determine the stage of a cancer. A sputum specimen would be needed to diagnose the cancer, not the stage of the disease.

An unconscious client is brought to the emergency department. The client's friend states, "We went to a party, took some pills, and drank beer." Which finding will the nurse expect when assessing the client? 1. Hyper-reflexive reflexes 2. Muscle spasms 3. Shallow respirations 4. Tachypnea

3. The client has taken a combination of pills and alcohol and cannot be roused. This has probably caused the client to breathe shallowly, which, if action is not taken immediately, could lead to respiratory arrest. The nurse would not expect to find tachypnea and does not have enough information about which drugs the client took to expect muscle spasms or hyperreflexia.

The nurse is caring for a client prescribed continuous positive airway pressure (CPAP). The client asks the nurse, "Will I have to wear an oxygen mask?" Which response by the nurse is best? 1. "Yes, a mask is what provides you with 100% oxygen." 2. "No, a mask is not required with CPAP devices." 3. "Yes, a mask provides pressurized oxygen so you can breathe more easily." 4. "It depends on the type of machine you decide to purchase for home use."

3. The client will have to use a mask with a CPAP. The mask provides pressurized oxygen continuously through both inspiration and expiration. By providing a client with pressurized oxygen, the client has less resistance to overcome in taking in the next breath, making it easier to breathe. The mask can be set to deliver any amount of oxygen needed.

When providing education for the client about the importance of blood levels in relation to breathing, what is the nurse's best explanation? 1. "The level of hemoglobin has no effect on oxygenation." 2. "The more hemoglobin you have the less oxygen in your body." 3. "Low hemoglobin levels cause reduced oxygen-carrying capacity." 4. "Low hemoglobin levels cause increased oxygen-carrying capacity."

3. The level of hemoglobin in one's body does have an effect on oxygenation. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin would increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood.

At 0800, the nurse assesses a client scheduled for surgery at 1000. The nurse observes dyspnea, nonproductive cough, and back pain. What is the nurse's priority action? 1. Ensure the chest x-ray was done yesterday, as prescribed 2. Check the serum electrolyte levels and complete blood count (CBC) 3. Immediately notify the healthcare provider of these findings 4. Sign the preoperative checklist for this client

3. The nurse should make sure that the healthcare provider is immediately notified of the findings because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should check any prescribed tests (such as chest x-ray, serum electrolyte levels, and CBC) after notifying the healthcare provider because they may help explain the change in the client's condition. The nurse should sign the preoperative checklist after notifying the healthcare provider of the client's condition and learning the healthcare provider's decision on whether to proceed with surgery.

A client was given intravenous morphine sulfate for pain as prescribed. The client is sleeping and has a respiratory rate of 6 breaths/minute. What will the nurse do next? 1. Notify the healthcare provider. 2. Begin cardiopulmonary resuscitation (CPR). 3. Attempt to arouse the client. 4. Administer naloxone.

3. The nurse would first attempt to arouse the client. Opioids suppress the respiratory center in the medulla and can cause respiratory arrest. The nurse will notify the healthcare provider after arousing and assessing the client. CPR is needed if the client is not breathing and does not have a heart rate. Naloxone would be needed if the client cannot be aroused or continues to decline.

A critically ill client's chest x-ray shows fluid in the alveolar spaces. The nurse notes the client is severely short of breath. Which prescription will the nurse anticipate? 1. Give albuterol. 2. Administer ibuprofen. 3. Prepare client for intubation. 4. Initiate airborne precautions.

3. The nurse would suspect the client has acute respiratory distress syndrome (ARDS), where the alveolar membranes are more permeable and the alveolar spaces are filled with fluid. The fluid interferes with gas exchange and reduces perfusion. Treatment for ARDS includes intubation, mechanical ventilation, vasoconstrictors, norepinephrine, and an induced coma. Albuterol is a bronchodilator given to asthma clients. Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), is given to relieve pain, decrease inflammation, and reduce fever. Standard precautions are needed for clients with ARDS.

A client with a pulmonary embolism is having a vena cava filter inserted. What is the best explanation by the nurse for the filter? 1. The filter prevents further clot formation 2. The filter collects clots so they do not go to the lungs 3. The filter breaks up clots into insignificantly small pieces 4. The filter contains anticoagulants that are slowly released, dissolving any clots

3. The umbrella-like filter is placed in a client at high risk for the formation of more clots that could potentially become pulmonary emboli. The filter breaks the clots into small pieces that will not significantly occlude the pulmonary vasculature. The filter does not release anticoagulants and does not prevent further clot formation. The filter does not collect the clots; if it did, it would have to be emptied periodically, causing the client to require surgery in the future.

A client has been prescribed a new drug for hypertension. Thirty minutes after taking the drug, the client develops chest tightness, becomes short of breath and tachypneic, and exhibits an altered level of consciousness. Which complication does the nurse expect? 1. The client is having an asthma attack 2. The client is having a pulmonary embolism 3. The client is experiencing medication hypersensitivity 4. The client is suffering from rheumatoid arthritis

3. These signs indicate a hypersensitivity to the new medication, leading to anaphylaxis and respiratory failure. An asthma attack is characterized by wheezing. A client with pulmonary embolism typically has chest pain with inspiration and hypoxemia. Rheumatoid arthritis does not cause respiratory symptoms.

A client who has just undergone a pneumonectomy asks the nurse which position is best when lying in bed. What is the nurse's best response? 1. "Always lie on the nonoperative side." 2. "It does not matter. Any position is fine." 3. "Always lie prone when you are in bed." 4. "Lie on the operative side or on the back."

4. A client who has undergone a pneumonectomy does not have a chest tube in place; therefore, the client can lie on the operative side. In fact, the best position for this client is to lie on the operative side or on the back to prevent fluid from draining into the unaffected lung and to promote maximum ventilation. The client should not lie on the nonoperative side, which would allow unwanted drainage.

A client with a large pulmonary embolism has results from an arterial blood gas analysis indicating respiratory alkalosis. What will the nurse determine is the potential cause of this finding? 1. Hypoventilation 2. Alveolar damage 3. Large amount of bloody sputum 4. Large region of lung tissue unavailable for perfusion

4. A client with a large pulmonary embolism would have a large region of lung tissue unavailable for perfusion. This causes the client to hyperventilate and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen, resulting in respiratory alkalosis. A client with respiratory alkalosis would hyperventilate and not hypoventilate. Alveolar damage and large amount of bloody sputum can be present with a pulmonary embolus, but they do not cause respiratory alkalosis.

The nurse will monitor a client suspected of having a primary tuberculosis (TB) infection for which finding? 1. Secondary pneumonia 2. Active TB within 1 month 3. A fever requiring hospitalization 4. A positive skin test

4. A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people would remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime often because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.

A client with a positive result on a skin test for tuberculosis (TB) is not showing signs of active disease. Still, the client is worried and asks the nurse what can be done to help prevent the development of active TB. The nurse will anticipate educating the client on which medication regimen? 1. Metronidazole therapy for 10 to 14 days 2. Metronidazole therapy for 2 to 4 weeks 3. Isoniazid therapy for 3 to 6 months 4. Isoniazid therapy for 9 to 12 months

4. Because of the increasing incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts for 9 to 12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results. Metronidazole is an antibiotic but is not normally used in the treatment of TB.

After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which response by the nurse is best? 1. "The chest tube was inserted improperly." 2. "It is normal for the drainage to be dark red." 3. "An artery was nicked during insertion." 4. "We are going to treat you for a hemothorax."

4. Because of the traumatic cause of injury, the client most likely has a hemothorax, in which blood collection causes the collapse of the lung. The placement of the chest tube would drain the blood from the space and re-expand the lung. There is a slight chance of nicking an intercostal artery during insertion, but it is fairly unlikely if the person placing the chest tube has been trained. The initial chest x-ray would help confirm whether there was blood in the pleural space or just air. It is not normal for chest tube drainage to be dark red, and it is not likely that the chest tube was inserted improperly.

During a pneumonectomy, the phrenic nerve on the surgical side is typically cut to cause hemidiaphragm paralysis. What is the best explanation for the nurse to use when teaching the client about this procedure? 1. Paralyzing the diaphragm reduces oxygen demand 2. Cutting the phrenic nerve is a mistake during surgery 3. The client is no longer using that lung to breathe 4. Paralyzing the diaphragm reduces the space left by the pneumonectomy

4. Because the hemidiaphragm is a muscle that does not contract when paralyzed, an uncontracted hemidiaphragm remains in an "up" position, which reduces the space left by the pneumonectomy. Serous fluid has less space to fill, thus reducing the extent and duration of mediastinal shift after surgery. Although it is true that the client no longer needs the hemidiaphragm on the operative side to breathe, this alone would not be sufficient justification for cutting the phrenic nerve. Paralyzing the hemidiaphragm does not significantly decrease total-body oxygen demand.

A client diagnosed with active tuberculosis is started on triple antibiotic therapy. Which findings indicate to the nurse the client's therapy is inadequate? 1. Decreased shortness of breath and absent cough 2. Improved chest x-ray and no reports of chest pain 3. Nonproductive cough and decreased night sweats 4. Acid-fast bacilli in a sputum sample after 2 months of treatment

4. Continuing to have acid-fast bacilli in the sputum after 2 months indicates continued infection. The other choices indicate improvement.

A client who is having difficulty breathing is told by the healthcare provider that oxygen will be prescribed due to collapsed alveoli. Which statement made by the nurse best explains to the client how opening up the collapsed alveoli improves oxygenation? 1. "Alveoli need oxygen to live." 2. "Alveoli have no effect on oxygenation." 3. "Collapsed alveoli increase oxygen demand." 4. "Gaseous exchange occurs in the alveolar membrane."

4. Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs. Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, although by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.

A client arrives in the emergency department displaying apnea, altered mental status, dyspnea, and central cyanosis. The client was found inside a car in the garage by neighbors while the motor was still running. Which findings will the nurse expect to observe while assessing this client? 1. Dilated pupils 2. Chest pains 3. Increased breath sounds 4. Cherry-red mucous membranes

4. In a client with late-stage carbon monoxide poisoning, the nurse would see cherry-red mucous membranes. Key signs of asphyxia are agitation, altered respiratory rate, anxiety, altered mental status, decreased breath sounds, dyspnea, and central and peripheral cyanosis. The client would not experience chest pains or dilated pupils as a result of carbon monoxide poisoning.

A 72-year-old client who has chronic respiratory disease comes to the clinic for a follow-up appointment. The nurse informs the client it is time for the pneumococcal and flu vaccines. What is the nurse's best explanation to the client for these injections? 1. "All clients are recommended to have these vaccines annually." 2. "These vaccines produce bronchodilation and improve oxygenation." 3. "These vaccines help reduce tachypnea in clients with chronic diseases." 4. "Getting these vaccines may help prevent life-threatening complications."

4. It is highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause respiratory failure, and these clients may need to be intubated and mechanically ventilated. The vaccines have no effect on respiratory rate or bronchodilation. The influenza vaccine is recommended for all clients older than 6 months of age annually. The pneumococcal vaccine is recommended for clients older than 65 years of age.

An older adult client who recently had surgery for a fractured right femur develops acute shortness of breath and progressive hypoxia requiring mechanical ventilation. The nurse knows that what is the most likely cause of this client's hypoxia? 1. Asthma attack 2. Atelectasis 3. Bronchitis 4. Fat embolism

4. Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. It is unlikely the client has developed asthma or bronchitis without a previous history. The client could have atelectasis, but it typically does not produce progressive hypoxia.

A client has been diagnosed with lung cancer. When the family members are informed of the diagnosis, they begin crying and shouting. Which statement by the nurse to the family is best? 1. "I understand this is shocking and not the news you wanted to hear." 2. "Please remain calm. You need to be strong for your loved one." 3. "If you do not calm down, I will have to have you removed from the unit." 4. "I can tell you are very upset. Please sit and talk with me about your feelings."

4. Lung cancer is a devastating diagnosis for family members to hear. The nurse would acknowledge and discuss the family's feelings. Stating this is not what the family wanted to hear or to remain calm does not address the family's immediate need. Telling the family they may be removed could lead to confrontation.

A client arrives in the local clinic and reports a chronic cough and fatigue. The client admits to smoking two packs of cigarettes daily for 10 years and also informs the nurse of a 19.8 lb (9 kg) weight loss over the last 2 months. The healthcare provider suspects cancer. The nurse will anticipate preparing the client for which test? 1. Bronchoscopy 2. Chest x-ray 3. Chest computed tomography (CT) 4. Surgical biopsy

4. Only surgical biopsy with cytologic examination of the cells can give a definitive diagnosis of the type of cancer. Bronchoscopy gives positive results in only 30% of the cases. Chest x-ray and computed tomography (CT) can identify the location of cancer but not diagnose the type.

A client is diagnosed with chronic obstructive pulmonary disease (COPD). Which statement will the nurse include when discharging this client? 1. "Check your oxygen saturation levels daily." 2. "You need to decrease your oral fluid intake." 3. "You can use home remedies to treat respiratory infections." 4. "Let's review how to recognize signs of a respiratory infection."

4. Respiratory infection in clients with a respiratory disorder can be fatal. It is important for the client ti understand how to recognize impending respiratory infection. Oxygen saturation assessment would not prevent complications. The client should be taught to increase fluid intake to help thin secretions. If the client has signs and symptoms of an infection, the client should contact the healthcare provider at once to obtain prompt treatment, not rely on home remedies.

A client presents with shortness of breath and absent breath sounds on the right side, from the apex to the base. The nurse prepares to provide the client care for which condition? 1. Acute asthma 2. Chronic bronchitis 3. Pneumonia 4. Spontaneous pneumothorax

4. Spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation; this results in shortness of breath with absent breath sounds. A client with an asthma attack would present with wheezing breath sounds, and bronchitis would be indicated by auscultating rhonchi. Bronchial breath sounds over the area of consolidation would indicate pneumonia.

A client is admitted with a fever, cough with copious secretions, and chest pain. Which test will the nurse ensure is performed prior to giving an antibiotic? 1. Arterial blood gas (ABG) analysis 2. Chest x-ray 3. Blood cultures 4. Sputum culture and sensitivity

4. Sputum culture and sensitivity can help identify the organism causing the pneumonia and should be done prior to giving an antibiotic. A chest x-ray can show the presence of lung infiltrates, confirming the diagnosis, but should be done after starting an antibiotic. ABG analysis helps determine the extent of hypoxia present due to the pneumonia, and blood cultures help determine if the infection is systemic, but these also may be done after starting the antibiotic.

A client is admitted with signs and symptoms of early pneumonia. The nurse will monitor the client for which complication? 1. Atelectasis 2. Bronchiectasis 3. Effusion 4. Inflammation

4. The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and bronchiectasis indicate a collapse of a portion of the airway that does not occur in pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.

A client with a pulmonary embolism is scheduled for an embolectomy. The client states, "I do not think I can have this surgery." Which response by the nurse is most appropriate? 1. "Do you know that not having this procedure could lead to death?" 2. "Surgery can be scary. Have you told your healthcare provider." 3. "I will let the operating room know to cancel your surgery." 4. "Can you share with me what you are feeling at this time?"

4. The nurse would discuss the client's feelings to determine why the client believes surgery cannot be performed. This discussion will guide the nurse's additional actions. The nurse should not make threatening comments, tell the client to speak with the healthcare provider, or immediately cancel the procedure.

A client arrives in the emergency department with smoke inhalation due to a house fire. What is the priority nursing action for this client? 1. Checking the oral mucous membranes 2. Checking for any burned areas 3. Obtaining a medical history 4. Ensuring a patient airway

4. The nurse's priority is to make sure the airway is open and the client is breathing. Check the mucous membranes and burned areas is important, but not as vital as maintaining a patient airway. Obtaining a medical history can be pursued after ensuring a patient airway.

A client is placed on oxygen therapy via a nasal cannula. Which action will the nurse complete first? 1. Make sure all the electronic monitoring devices in use are properly grounded. 2. Know the location of the O₂ turn-off valve on the nursing unit. 3. Instruct the client and family, as well as visitors, not to smoke. 4. Confirm the healthcare provider's prescription for oxygen.

4. The priority when administering oxygen is to check the healthcare provider's prescription because this is considered a medication. The nurse also should make sure all electronic monitoring devices are grounded, instruct everyone not to smoke, and know the location of the turn-off valve for the O₂, but these actions should be taken after confirming the healthcare provider's prescription for oxygen.

A client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. The client is tachypneic with a prolonged expiratory phase but has no cough. The nurse observes the client leaning forward with arms braced on the knees to support the chest and shoulders for breathing. Based on these findings, the nurse anticipates which diagnosis? 1. Acute respiratory distress syndrome (ARDS) 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

4. These are classic signs and symptoms of a client with emphysema. Clients with asthma are acutely short of breath during an attack and appear very frightened. Clients with bronchitis are bloated and cyanotic in appearance, and clients with ARDS are acutely short of breath and require emergency care.

Which client will the nurse monitor most closely for the development of a complication with lung function? 1. A client scheduled for an appendectomy 2. A client with a meniscus tear 3. A client with sleep apnea 4. A client with thoracic kyphoscoliosis

4. Thoracic kyphoscoliosis causes lung compression, restricts lung expansion, and results in more rapid and shallow respiration. An otherwise healthy client who is scheduled for an appendectomy or has a meniscus tear would not experience any problems with lung function due to either of these illnesses. Clients with sleep apnea also would not normally have problems with lung function.

The nurse recognizes which client is at highest risk for developing a pulmonary embolism? 1. An ambulatory client with an inflammatory joint disease 2. An ambulatory client who has type 1 diabetes 3. A healthy client who is 6 months pregnant 4. A client who has fractures of the pelvis and right femur

4. Thrombosis formation is caused by abnormalities in blood flow, vein wall integrity, and blood coagulation. The client with pelvic and femur fractures would be immobilized and probably have edema, which leads to venous stasis and predisposes the client to the development of deep vein thrombosis. A pulmonary embolus commonly arises from clots in the deep veins of the legs that break off and travel to the pulmonary arteries. The risk of developing venous thrombosis is not as high with the other conditions.

A client returns to the acute care unit after abdominal surgery. Which intervention will the nurse perform for the client? 1. Chest physiotherapy 2. Mechanical ventilation 3. Reduce oxygen requirements 4. Use of an incentive spirometer

4. Using an incentive spirometer requires the client to take deep breaths and promote lung expansion. Chest physiotherapy helps mobilize secretions but will not prevent atelectasis. Reducing oxygen requirements or placing someone on mechanical ventilation does not affect the development of atelectasis.

The nurse knows which client is at the highest risk for respiratory failure? 1. A client with breast cancer 2. A client with a cervical sprain 3. A client with a fractured hip 4. A client with Guillain-Barré syndrome

4. Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause ascending paralysis and potential for respiratory failure. The other conditions typically do not affect the respiratory system.

The nurse is caring for a client with emphysema. Which finding(s) will the nurse expect to report to the primary healthcare provider immediately? Select all that apply. 1. Increased residual lung capacity 2. Dyspnea and pink color 3. Prolonged expiratory phase 4. Decreased expiratory flow rate 5. Cyanosis

5. The nurse would report cyanosis. Because of the large amount of energy it takes to breathe, clients with emphysema are usually pink, not cyanotic, and they usually breathe through pursed lips. Clients with emphysema usually have an increased residual lung capacity and volume, as well as decreased elastic recoil. They also have a prolonged expiratory phase and decreased expiratory flow rate. They also suffer from dyspnea.

A client, following the administration of meperidine, has a PaCO₂ value of 80 mm Hg. How will the nurse interpret this finding? 1. A mild case of hyperventilation 2. Perfectly normal 3. At risk for developing mild pneumonia 4. At risk for respiratory arrest

4. A client about to go into respiratory arrest would have inefficient ventilation and would be retaining carbon dioxide. The PaCO₂ value expected would be around 80 mm Hg. It is not indicative of hyperventilation, as the CO₂ is high, or pneumonia, as this value does not rise in pneumonia.

Which instruction is priority for the nurse to provide to a client regarding therapy for active tuberculosis (TB)? 1. "It is okay to miss a dose of your medication every day or two." 2. "If adverse effects occur, stop taking the medication." 3. "Only take the medication until you feel better." 4. "You must comply with the medication regimen to treat TB."

4. The treatment regimen for TB may last up to 24 months. It is essential that the client comply with therapy during that time or resistance will develop. At no time should the client stop taking the medications without the primary healthcare provider's approval.

When a client is placed on oxygen therapy, the nurse will follow protocol. Place the following steps in the correct order the nurse will complete them. Use all options. 1. Attach the flow meter to a wall outlet, fill the humidifier with water, and attach the delivery system and tubing. 2. Explain the procedure to the client. 3. Check the healthcare provider's prescription. 4. Place the face mask or cannula on the client. 5. Reassess the client and document the procedure.

Ordered Response: 3, 2, 1, 4, 5.