Respiratory Disorders

What nursing observation indicates the cuff on an endotracheal tube is leaking? 1. An increase in peak pressure on the ventilator 2. Client is able to speak. 3. Increased swallowing efforts by client 4. Increased crackles (rales) over left lung field

2 A leak in the cuff would allow air to pass through the trachea and vocal cords, allowing the client to make a noise—or to speak. The nurse may also hear the air leak. An air leak may occur when there are changes in the pressure on the ventilator, but this is not the most common cause or the best response from the nurse. Increased swallowing is indicative of irritation in the throat. Increase in adventitious sounds indicates excessive mucus in the lungs.

For a client with COPD, what is the main risk factor for pulmonary infection? 1. Fluid imbalance with pitting edema 2. Pooling of respiratory secretions 3. Decreased fluid intake and loss of body weight 4. Decreased anterior-posterior diameter of the chest

2 The ineffective clearing of secretions with resultant pooling can lead to an increased risk for infection. The client's appetite is usually decreased. The client has an increased anteroposterior diameter of the chest.

The nurse is caring for a client who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea; his pulse rate is 120 beats/min. In what order will the nurse provide care to this client? Number the following options in the order in which they will be performed, with 1 being the first action and 4 being the last action. 1. ________ Administer humidified oxygen. 2. ________ Place in semi-Fowler's position. 3. ________ Provide nebulizer treatment with bronchodilator. 4. ________ Discuss factors that precipitate attack.

2, 1, 3, 4 1.)___2___ Because oxygen is a priority, begin administration of oxygen. 2.)___1___ The first action is to place the client in semi-Fowler's position. Oxygen or inhalation therapy cannot be effective with severe orthopnea if the client is not in a sitting or upright position. 1057 3.)___3___ Then administer the nebulizer treatment, which would include bronchodilators. 4.)___4___ Physiologic needs must be addressed before teaching or psychosocial needs are considered.

The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea? 1. Decreased breath sounds are heard over the left side of the chest. 2. Increased rhonchi are present at the lung bases bilaterally. 3. Client is able to speak and coughs excessively. 4. Ventilator pressure alarm continues to sound.

1 An endotracheal tube that is inserted too far—beyond the carina—is most likely to enter the right main stem bronchus. The volume of air from the ventilator is only delivered to the right lung; breath sounds are decreased or absent over the left lung. The pressure alarm indicates that the current pressure is not adequate to deliver the tidal volume prescribed. This may occur but does not confirm the migration of the tube.

What symptoms would the nurse expect to observe in a 19-month-old client with a diagnosis of laryngotracheobronchitis (LTB)? 1. Stridor on inspiration 2. Expiratory wheezing 3. Paroxysmal coughing 4. Hemoptysis

1 Because croup causes upper airway obstruction, inspiratory stridor is a predominant symptom. Expiratory wheezing is heard in the asthmatic client. Paroxysmal coughing occurs more with spasmodic laryngitis. Hemoptysis is not common with croup syndromes.

What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult? 1. Acute confusion 2. Hypertension 3. Hematemesis in the morning 4. Dry hacking cough at night

1 Confusion in the older adult is related to hypoxemia, which occurs with pneumonia. Vasodilation and dehydration cause hypotension and orthostatic changes. Crackles are typically heard when fluid is in the alveolar area. The cough is generally productive. The breathing is rapid and shallow without the use of accessory muscles. Hemoptysis may occur, but not hematemesis (blood from the GI tract).

The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client's condition? 1. Respiratory rate of 18 breaths/min 2. Pulse oximetry of 88% 3. Pulse rate of 110 beats/min 4. Productive cough with rapid breathing

1 The respiratory rate is within normal limits at 18 breaths/min. The option for the pulse oximetry is too low. The pulse rate is too high to indicate improvement, and the productive cough with rapid breathing is not as significant as the decrease in respiratory rate.

The nurse is caring for an infant who is experiencing respiratory distress and being treated with continuous positive airway pressure (CPAP). The nurse knows that for this treatment to be most effective, the infant must be: 1. Intubated with respiration maintained by controlled ventilation 2. Able to breathe spontaneously 3. Frequently stimulated to maintain respiratory rate 4. Suctioned frequently to maintain alveolar ventilation

2 CPAP only works when the infant is breathing on his own. When the airway is opened for a breath, the CPAP increases the pressure in the airway, which increases airflow to the lungs and oxygenation. CPAP is not used when a child requires controlled ventilation. Stimulating the infant may be appropriate, but the child must be able to breathe spontaneously for this to be effective. The child is not suctioned unless an excessive amount of mucus must be removed.

16. A client has a diagnosis of right-sided empyema. Thoracentesis is to be performed in the client's room. The nurse will place the client in what position for this procedure? 1. Prone position with feet elevated 2. Sitting with upper torso over bedside table 3. Lying on left side with right knee bent 4. Semi-Fowler's position with lower torso flat

2 Positioning over the bedside table allows the ribs to separate, which assists the physician in positioning the needle into the pleural cavity. If the client is unable to assume a sitting position, he or she is placed on the affected side with head of bed slightly elevated. The area containing the fluid should be dependent.

The nurse understands clamping a chest tube may cause what problem? 1. Atelectasis 2. Tension pneumothorax 3. Bacterial infections in the pleural cavity 4. Decrease in the rate and depth of respirations

2 Tension pneumothorax occurs when air enters the pleural space with each inspiration, becomes trapped there, and is not expelled during expiration (i.e., one-way valve effect). Pressure builds in the chest as the accumulation of air in the pleural space increases. This can lead to a mediastinal shift. Atelectasis occurs when the atmospheric pressure enters the pleural cavity. This procedure has nothing to do with an infection or pulmonary consolidation.

A client has a history of atherosclerotic heart disease with a sustained increase in his blood pressure. What is important to discuss with this client before he uses an over-the-counter decongestant? 1. Urinary frequency and diuresis 2. Bradycardia and diarrhea 3. Vasoconstriction and increased arterial pressure 4. Headache and dysrhythmias

3 Decongestants should be avoided by clients with hypertension because these medications often contain pseudoephedrine and phenylephrine, which cause central nervous system stimulation with vasoconstriction and increased blood pressure. They also precipitate anxiety and insomnia. Decongestants do not cause urinary frequency, diuresis, or dysrhythmias.

Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that which problem may occur if the client receives too much oxygen? 1. Hyperventilation 2. Tachypnea 3. Hypoventilation or apnea 4. Increased snoring

3 In clients with chronic high Pco2 levels (COPD), the administration of oxygen at a flow rate that increases the Pao2 may cause apnea and require the use of a bag valve mask resuscitator to ventilate the client. When the Pao2 increases significantly, it can decrease the client's stimulus to breath and may cause carbon dioxide narcosis.

On the first postoperative day after a right lower lobe (RLL) lobectomy, the client deep-breathes and coughs but has difficulty raising mucus. What nursing observation would indicate the client is not adequately clearing secretions? 1. Chest x-ray film showing right-sided pleural fluid 2. A few scattered crackles on RLL on auscultation 3. Increase in Paco2 from 35 to 45 mm Hg 4. Decrease in forced vital capacity

3 Retained secretions may cause hypoventilation; this results in an increase in the Paco2. The other options do not as effectively reflect a problem with clearing mucus. Pleural fluid is not removed via coughing; the fluid is in the pleural space, not in the lung. Although the Paco2 is within the normal limits, there is still an increase noted, which is due to the hypoventilation. The nurse cannot easily measure the forced vital capacity at the bedside.

On auscultation, the nurse hears wheezing in a client with asthma. Considering the pathophysiology of asthma, what would the nurse identify as the primary cause of this type of lung sound? 1. Increased inspiratory pressure in the upper airways 2. Dilation of the respiratory bronchioles and increased mucus 3. Movement of air through narrowed airways 4. Increased pulmonary compliance

3 The wheezing is due to narrowing of the airway caused by bronchospasm. Increased mucous production hinders the airway as well; this also results in trapping of air in the alveoli. Increased pulmonary compliance indicates the lungs have good recoil and expansion.

While a client's wife is visiting, she observes the client's chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse? 1. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it." 2. "I have checked all of the equipment and it is working fine; you do not need to worry about it." 3. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding." 4. "The chest tube is draining the secretions from his chest; it is important for him to deep-breathe frequently."

3 This is important information to explain to the client's wife regarding the bloody drainage in the chest tube collection system. After the nurse has explained the reason for the drainage, it would then be appropriate to sit down and talk with the wife. Checking the equipment may be appropriate; however, telling the wife not to worry is a communication block (false reassurance). Having the client breathe deeply does not answer the question or address the wife's concern.

A 6-year-old client is admitted to the postoperative recovery area after a tonsillectomy. In what position will the nurse place the client? 1. Semi-Fowler's position, with the head turned to the side 2. Prone position, with the head of the bed slightly elevated 3. On the back, with the head turned to the right side 4. On the abdomen, with the head turned to the side

4 Before the child is fully awake, he or she should be placed on the abdomen with the head turned to one side to facilitate the drainage of secretions and to prevent aspiration. When alert, the child may sit up or assume a position of comfort. The other options are not appropriate because they do not allow for drainage of secretions from the mouth and throat after a tonsillectomy while the child is in early recovery.

The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information? 1. "You should avoid emotional situations that increase his shortness of breath." 2. "Help your husband arrange activities so that he does as little walking as possible." 3. "Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening." 4. "Your husband will be more short of breath when he walks, but that will not hurt him."

4 Physical conditioning is important for clients with COPD. Activity needs to be paced so that undue fatigue does not occur. Some increase in shortness of breath with exercise is to be expected but will not damage the lungs. If the client stops exercising before an increase in shortness of breath, he will not experience a training effect.

Which statement correctly describes suctioning through an endotracheal tube? 1. The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn. 2. The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway. 3. With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn. 4. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

4 The catheter must be advanced to an adequate depth (to prevent secretion buildup at the end of the tube and to clear the airway as much as possible). To minimize trauma, suction is applied only during catheter withdrawal. If the upper airway is suctioned, another sterile catheter must be obtained to suction the ET tube.

The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home? 1. Because of his need for oxygen, the client will have to limit activity at home. 2. The use of oxygen will eliminate the client's shortness of breath. 3. Precautions are necessary because oxygen can spontaneously ignite and explode. 4. Use oxygen during activity to relieve the strain on the client's heart.

4 The primary purpose of oxygen therapy is to decrease the workload of the heart in clients with chronic pulmonary diseases and to assist in preventing right-sided heart failure. Use of oxygen may help to relieve shortness of breath but will not eliminate it. Oxygen supports combustion but is not explosive; supplemental oxygen will allow more activity for the client, not less.

TB is transmitted through: A. inhalation of infected droplets. B. contact with blood. C. the fecal-oral route. D. skin-to-skin contact.

A. TB spreads by inhalation of droplet nuclei when an infected person coughs or sneezes.

Your patient's ABG analysis shows a pH less than 7.35, bicarbonate greater than 26 mEq/L, and a PaCO2 greater than 45 mm Hg. He's diaphoretic, has tachycardia, and is restless. Which condition does he probably have? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. The patient with respiratory acidosis can display all of these signs and symptoms and can also have headache, confusion, apprehension, and a flushed face.

Which type of breath sound is medium-pitched and continuous, occurs over the upper third of the sternum in the interscapular area, and is equally audible during inspiration and expiration? A. Vesicular B. Bronchial C. Bronchovesicular D. Tracheal

C. Bronchovesicular breath sounds demonstrate these characteristics.

When suctioning a patient, you should: A. apply suction intermittently as the catheter is inserted. B. suction the patient for longer than 10 seconds each time. C. oxygenate the patient's lungs before and after suctioning. D. apply suction continuously while inserting the catheter.

C. The patient should be oxygenated before and after suctioning to reduce the risk of hypoxemia. Avoid suctioning for longer than 10 seconds and apply suction intermittently as you withdraw — not insert — the catheter.