respiratory EAQ

The hepatitis B positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine?

0.5 mL intramuscularly within 12 hours of birth HBIG must be given within 12 hours of birth to be effective. The correct dose is 0.5 mL, and it must be given intramuscularly. The vaccine is not given subcutaneously.

Which client is at the greatest risk for a postpartum infection?

A woman who required catheterization after voiding less than 75 mL Repeated catheterizations for residual urine increase the chance that bacteria will be introduced and their growth fostered. The size of the newborn does not predispose the mother to postpartum infection. A hemoglobin level of 11 g does not reflect the highest risk for infection; a hemoglobin of 11 g is at the low end of the acceptable range. A loss of 250 to 500 mL of blood is considered acceptable.

A client in labor at 39 weeks' gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?

Active genital herpes Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacological.

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

Apply a precut dressing around the insertion site with the flaps pointing upward To prevent unraveling and potential aspiration into the airway, only a precut dressing should be used around the site. It should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula. The use of sterile cotton balls to cleanse the outer cannula is contraindicated; cotton balls have small threads that may be inhaled. The status of the cuff has no effect on tracheostomy care.

A client returning from a bronchoscopy is directed to not consume any food or drink any fluids for several hours. The nurse explains that these measures are taken to prevent what?

Aspiration To allow for the insertion of the bronchoscope, throat muscles are anesthetized, diminishing the protective gag reflex. Dysphasia is difficulty in talking and does not occur with a bronchoscopy. Projectile vomiting does not occur after a bronchoscopy. A general anesthetic usually is not used; therefore, paralytic ileus is not a complication.

A client is receiving morphine sulfate for severe metastatic bone pain. What should the nurse do to prevent complications from a common, serious side effect of morphine?

Assess for altered breathing patterns Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.

A nurse reviews the use of an incentive spirometer with a client. What client action indicates the need for further instruction?

Blowing vigorously into the mouthpiece The client should exhale before inhaling slowly and deeply through the spirometer to maximize lung expansion. Sitting in a chair will facilitate diaphragmatic excursion and help maximize lung expansion. Coughing will help remove secretions mobilized by use of a spirometer. The client's lips must form a seal around the mouthpiece to measure the volume of air inhaled.

After multiple bee stings a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what?

Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client?

Carbon dioxide retention loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis). Tissue necrosis results from localized tissue anoxia and will not cause the systemic response of respiratory acidosis. Normal oxygen saturation of hemoglobin is 95% to 100%, so this is not a sign of acidosis. An increased respiratory rate may lead to respiratory alkalosis.

A nurse is teaching a client with tuberculosis about recovery after discharge from the hospital. Which instruction is the priority?

Consistently taking prescribed medication Tubercle bacilli are particularly resistant to treatment and can remain dormant for prolonged periods; medication must be taken consistently as prescribed for prolonged periods. Although having sufficient rest is important, microorganisms must be eliminated by the use of medication. Although getting plenty of fresh air is important, microorganisms must be eliminated by the use of medication. Although changing the current lifestyle is important, microorganisms must be eliminated by the use of medication.

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3-kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?

Cor pulmonale A sudden weight gain is an initial sign of right ventricular failure caused by COPD. Polycythemia is associated with polycythemia vera, not COPD. A sudden weight gain is not associated with compensated acidosis. Right, not left, ventricular failure occurs with COPD.

A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange?

Decreased oxygen intake The presence of abdominal viscera in the thoracic cavity impinges on the lungs and affects their ability to expand, thus limiting the amount of air that can enter the lungs and alveoli. In addition, these newborns tend to have underdeveloped lungs. An incarcerated hernia, although a medical emergency, does not impair gas exchange on a long-term basis. The basal metabolic rate is not increased with a diaphragmatic hernia. Excessive secretions do not occur with a diaphragmatic hernia.

A nurse concludes that a client's withdrawn behavior may temporarily provide what?

Defense against anxiety Withdrawal provides a temporary defense against anxiety because it limits contact with reality and reduces the client's world. Withdrawal does not provide a basis for emotional growth, time for internal problem-solving, or a delay in which the client can organize personal resources because feelings and anxieties are still present and little attempt is made to work through problems.

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." What should be the nurse's initial response?

Discuss the client's concerns Addressing the client's feelings and then exploring preventive measures should reduce anxiety. The risk of a pulmonary embolus is a real concern, not a misconception, associated with thrombophlebitis. Explaining measures to prevent a pulmonary embolus is not the client's concern; this response does not address the client's feelings concerning the risk of sudden death. Teaching recognition of early signs and symptoms of pulmonary emboli disregards the client's expressed fears and may increase anxiety.

A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do?

Divide the staff into opposing factions to gain self-esteem

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation?

Early unexplained restlessness Early unexplained restlessness is a central nervous system sign of inadequate oxygenation that may be observed in the client with a respiratory disorder. Late cyanosis is a cardiovascular sign of inadequate oxygenation. Early tachypnea and late use of accessory muscles are signs of inadequate oxygenation associated with the respiratory system.

client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications?

Eat yogurt daily Yogurt contains Lactobacillus acidophilus, which replaces the intestinal flora destroyed by antibiotics. The other options are not relevant to antibiotics or intestinal flora.

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). What should the nurse monitor for when assessing for this complication?

Elevated hemoglobin The body attempts to compensate for decreased oxygen to tissues by increasing the number of blood cells, the oxygen-carrying component of the blood. With polycythemia, the skin, especially the face, appears flushed, not pale. Dyspnea on exertion is not specific to polycythemia; there is more than one cause of dyspnea on exertion. The hematocrit is increased with polycythemia.

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, what is the most important nursing intervention?

Ensure nothing by mouth (NPO) until the gag reflex returns Ensuring nothing by mouth until the gag reflex returns prevents aspiration. Although assessing for signs of hemoptysis is important because hemoptysis can occur after these procedures, it is not the priority. The supine position can promote aspiration. Checking for level of consciousness is unnecessary after this procedure.

The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe how often?

Every hour for the first 24 hours and then every 2 hours Excessive endotracheal secretions after a pneumonectomy require coughing routines that are effective but not exhausting. Every 15 minutes for the first 24 hours and then every 2 hours, and every 30 minutes for the first 24 hours and then every 2 hours are too exhausting. Every 2 hours for the first 24 hours and then every 3 hours is not specific for a client who has had a pneumonectomy. Every hour for the first 24 hours and then every 2 hours would be appropriate for this client.

A client would benefit from diaphragmatic breathing. What should the nurse advise the client to do?

Expand the abdomen on inhalation Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position other than the prone or Trendelenburg; usually the semi-Fowler position is used.

A client reports frequent awakening at night, insomnia, and excessive daytime sleepiness. The client adds that his bed partner also complains about his loud snoring. What does the nurse anticipate including in the patient's teaching plan?

Get fitted for an oral appliance that will bring the lower jaw and tongue forward Frequent awakening at night, insomnia, excessive daytime sleepiness, and loud snoring indicate obstructive sleep apnea. To help the client manage obstructive sleep apnea, the nurse may suggest that he get fitted for an oral appliance that will bring the mandible and tongue forward to enlarge the airway space. This will help prevent airway occlusion. A warm shower before bedtime may be suggested to a client who complains of sleeplessness resulting from anxiety or some other discomfort. The nurse should instruct the client to avoid taking sedatives and alcoholic drinks in the three to four hours before sleep.

The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter?

Gravity An indwelling urinary catheter always is positioned so that the level of the bladder is higher than the level of the drainage container; gravity promotes urine flow. Inertia refers to a property of matter. Osmosis refers to the movement of water across a semipermeable membrane; it is not responsible for the flow of urine through a catheter. Diffusion refers to the passage of molecules from an area of higher concentration to one of lower concentration.

A client, appearing anxious, has a respiratory rate of 40 shallow breaths per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. The nurse concludes that the client's complaints probably are related to what?

Hyperventilation The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these adaptations; if uninterrupted this can result in respiratory alkalosis. Eupnea is normal, quiet breathing; the client has shallow, rapid breathing. Kussmaul's respirations are deep, gasping respirations associated with diabetic acidosis and coma. These adaptations are related to a decreased carbon dioxide level in the body.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

I get a sharp, stabbing pain when I take a deep breath Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement?

I will maintain complete bed rest. Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority?

Immediately contact the primary health care provider The observation may be indicative of bleeding and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing only to monitor the client is unsafe. Monitoring vital signs every hour for four hours is a potentially life-threatening situation; the health care provider should be notified immediately. Increasing the coughing and deep breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.

A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment?

Increase Breath sound The chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function. Increased respiratory rate may be a sign of pain, respiratory obstruction, or bleeding. Crepitus detected on palpation of the chest indicates that air has entered the subcutaneous tissue (subcutaneous emphysema). Constant bubbling in the drainage collection chamber indicates a probable leak in the drainage system.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. What does the nurse plan to do to decrease the amount of secretions retained?

Increase fluid intake to at least 2 L a day Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary and when prescribed. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx. Placing the client in a high Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity.

A nurse is assisting the primary health-care provider in examining a client. The primary health-care provider confirms that the client has obstructive sleep apnea. Which physical symptoms does the nurse expect the client to report? Select all that apply.

Insomnia Morning headaches Frequent awakening at night Insomnia, morning headaches, and frequent nighttime awakening are physical clinical manifestations of obstructive sleep apnea. Therefore the nurse anticipates that the client will report these symptoms. Fatigue and decreased motivation may be expected as well, but these are are psychological signs of sleep deprivation.

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?

Instruct the client to splint the wound with a pillow when coughing Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the health care provider and then check for wound dehiscence.

A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. Why does the nurse anticipate this microorganism?

It inhabits the intestinal tract. E. coli is commonly found in the bowel and, because of anatomic proximity and possibly careless hygiene after bowel movements, may spread to the urethra. E. coli is not found in the kidneys. E. coli is no more virulent than other infective agents, nor does it compete with fungal organisms for host sites

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. Which type of respirations does the nurse expect the client to exhibit?

Kussmaul's breathing Kussmaul's breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that usually is associated with pathology of the respiratory center in the brain.

A client is diagnosed with tuberculosis associated with human immunodeficiency virus (HIV) infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started?

Liver function studies Antitubercular drugs, such as isoniazid and rifampin are hepatotoxic. Pulmonary function studies, electrocardiogram, and echocardiogram are not related to the administration of antitubercular drugs or to their side effects. The white blood cell count is expected to be higher in the presence of infection, but with acquired immunodeficiency syndrome (AIDS) the WBC count will be less than 2500/cm3, and helper T cells will number less than 200 mm3; the T4/T8 ratio will be 1:2. These tests will not provide information relative to starting antitubercular therapy or to its side effects.

When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by what?

Medulla The medulla oblongata contains the respiratory center, and the neurons that supply the respiratory muscles originate here; they produce the rhythmic pattern of inspiration and expiration. The cerebellum helps control skeletal muscles. The hypothalamus links the nervous system to the endocrine system and functions as a relay station between the cerebral cortex and lower autonomic centers. The cerebral cortex is unre

A nurse is caring for a client who has contracted a trichomonal infection. Which oral drug should the nurse anticipate that the health care provider will most likely prescribe?

Metronidazole (Flagyl) Metronidazole (Flagyl) is a potent amebicide. It is effective in eradicating the protozoan Trichomonas vaginalis. Penicillin is administered for its effect on bacterial, not protozoal, infections. Gentian violet is a local anti-infective that is applied topically; it may cause discoloration of the skin. It is effective against Candida albicans. Nystatin (Mycostatin) is an antifungal for infections caused by C. albicans.

The parents of a school-aged child with cystic fibrosis tell the nurse that they have changed to natural pancreatic enzymes because of money issues. What is an appropriate response by the nurse?

Natural enzymes are not as effective as the brand-name product Natural pancreatic enzymes are not considered adequate in children with cystic fibrosis because of the bioavailability of the enzymes. Pancreatic enzyme supplementation is a lifelong treatment for cystic fibrosis. All medications have side effects, and pancreatic enzymes should be taken with meals. Giving twice as many natural enzymes does not constitute accurate dosing.

The nurse is caring for a client that has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?

Night sweats and blood-tinged sputum Blood-tinged sputum, in the absence of pronounced coughing, often is the presenting sign of TB; diaphoresis at night is a later sign. Recurrent fever is present; frothy sputum occurs with pulmonary edema. A productive cough occurs with TB. A productive cough occurs with TB, but engorged neck veins occur with heart failure.

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. What is the priority nursing intervention?

Notify the health care provider immediately Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system; it functions via negative pressure, not gravity. Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.

When a 12-year-old boy who sustained several tick bites on a camping trip becomes ill, he is told that he may have Lyme disease. He asks the nurse, "What is Lyme disease?" What is the best response by the nurse?

They will not be contacted, because treatment at the clinic is confidential Federal law allows family planning clinics to maintain minors' confidentiality, although individual states may have different regulations; there is a concern that these teenagers will not seek or continue treatment if they fear disclosure. To maintain confidentiality, family planning clinics treat these adolescents as emancipated minors who can sign their own consent forms. Most family planning clinics receive funding and charge on a sliding scale based on income, thus encouraging adolescents to seek treatment. Telling the client that her parents will not be notified as long as she ensures that her sexual contacts come in for testing could be viewed as coercion; if the STI is reportable, follow-up of sexual partners is indicated, but the adolescent is not responsible for ensuring that they report for testing.

client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. What should the nurse suggest that the client do?

Use a humidifier in the bedroom A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early morning congestion.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

Wheezing Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase. An increased temperature is characteristic of sepsis, not asthma. Stridor is due to foreign body obstruction, not asthma. Hypertension, not hypotension, may occur with asthma.

A client with a diagnosis of tuberculosis is receiving isoniazid as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?

Yellow sclera

The nurse reviews common side effects of general anesthesia with a client scheduled for surgery. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience

a sore throat General anesthesia is delivered via an endotracheal tube that irritates the posterior pharynx and larynx. Side effects of general anesthesia do not include transient headaches or an elevated temperature. Hiccoughs, headaches, and an elevated temperature are systemic effects, not local effects, and are not side effects of general anesthesia

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. The nurse concludes that the severe dyspnea probably is caused by what?

Bronchial obstruction or pleural effusion Proliferation of malignant cells may obstruct the bronchial tree or foster development of exudate in the pleural space, decreasing the availability of oxygen and increasing retention of carbon dioxide. A tumor of the lung does not cause abdominal distention or pressure. Fluid retention as a result of renal failure is not associated with cancer of the lung. Although anxiety associated with pain may increase the respiratory rate, it will not cause difficulty with breathing

Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.

Having sexual intercourse Receiving blood transfusions HIV infection spreads through contact with infected body fluids such as blood, semen, vaginal secretions, and breast milk. Sexual intercourse is the most common cause of transmission of HIV infection. It can also be transmitted through transfusion of infected blood. Casual interactions such as sharing eating utensils, shaking hands with each other, and kissing each other do not result in transmission of HIV infection.

A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations?

Hyperventilation The client is hyperventilating and is blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted, this can lead to respiratory alkalosis. Shortness of breath is a sign of dyspnea. There is no evidence that the client is having difficulty breathing. Kussmaul respirations are deep, gasping respirations associated with diabetic acidosis and coma, not hyperventilation associated with anxiety. These clinical manifestations are related to a decreased, not increased, carbon dioxide level in the body.

A client who has syphilis tells the nurse that it must have been contracted from a toilet seat. The nurse knows that this cannot be true because of what property of the causative agent of syphilis?

It is inactivated when exposed to a dry environment A dry environment inactivates the Treponema pallidum, making it incapable of causing disease. The organism is transferred by sexual contact; warm, moist body contact supports growth of the organism. Nothing chelates this organism.

Several days after a client had a total laryngectomy, the health care provider prescribes a progressive diet as tolerated. What should the nurse do?

Keep suction apparatus readily available in case excessive respiratory secretions occur. Initial attempts at oral feeding may cause a choking feeling that may produce severe coughing that raises secretions. Effective coughing is difficult because with a laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive secretions may block the airway and must be removed by suctioning. Swallowing does not have an adverse effect on the suture line; a nasogastric tube is not used because it can traumatize the suture line. A progressive diet is started with liquids, not pureed foods. Airway patency is the priority, not administering medication for pain.

The nurse prepares an intravenous solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. Which condition will improve if the administration of lactated Ringer solution is effective?

Metabolic acidosis Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution.

Which condition may cause respiratory alkalosis?

Asthma Asthma causes respiratory alkalosis. Atelectasis, poliomyelitis, and cystic fibrosis cause respiratory acidosis, not respiratory alkalosis

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C&S) are prescribed. Place these interventions in the order in which they should be implemented.

Bed rest Oxygen via nasal cannula Specimens for C&S Administration of an antibiotic The client's respiratory status is the priority; bed rest reduces oxygen demands and the administration of oxygen increases oxygen to the alveolar capillaries; specimens for culture and sensitivity must be obtained before the administration of antibiotics, which prevents false microbiologic interpretation caused by the effect of the antibiotic.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. What are they best described as?

Moist rumbling sounds that clear after coughing Coarse rhonchi, particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.

A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply.

Providing mechanical ventilation Administering sodium bicarbonate The use of mechanical ventilation is necessary if the metabolic acidosis is severe and the client is in comatose stage. The administration of sodium bicarbonate can also be used to treat metabolic acidosis. If the client was conscious, then the nurse could help the client breathe into a paper bag to increase CO 2 levels. In respiratory acidosis, not respiratory alkalosis, CPAP is used to promote exhalation of carbon dioxide. The intermittent positive pressure breathing would be beneficial in respiratory acidosis, not respiratory alkalosis.

The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary?

Reduced oxygen levels can stimulate dysrhythmias. Inadequate oxygenation can cause premature ventricular complexes. Although the client will have closed-chest drainage in place, it does not explain why adequate oxygenation is important. Hypoxia can precipitate respiratory acidosis; hyperventilation causes respiratory alkalosis. Postoperative pain can increase the respiratory rate; increased respiratory rate does not increase the pain level.

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.

Observe for chest wall trauma Assess breath sounds and respiratory effort The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort. Establishment of a patent airway by positioning occurs during the assessment of the airway and cervical spine. Level of consciousness is evaluated to determine mental status of the client. Clothing is removed to perform a complete physical assessment of the client.

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply.

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed Identifying the causative agent for neutropenia is important for starting treatment. Therefore the priority nursing intervention is to obtain blood cultures immediately and administer antibiotic STAT as prescribed to the client. The nurse can monitor for rashes and pruritus after administering the medication. The nurse can prepare a diet plan and teach hygiene measures after stabilizing the client.

A client is admitted to the emergency department with a stab wound of the left thorax. How should the nurse position the client?

On the left side with the head of the bed elevated When the client lies on the affected side, the unaffected lung can expand to its fullest potential; elevation of the head facilitates respirations by reducing the pressure of the abdominal organs on the diaphragm, allowing the diaphragm to descend with gravity on inspiration. Maximum lung expansion is inhibited when the head is not elevated. Although the high-Fowler position facilitates diaphragmatic movement, it is unclear as to what "left side supported" means. Pressure against the right thorax limits right intercostal expansion and gaseous exchange in the right lung. The abdominal organs restrict contraction of the diaphragm when lying flat in bed; also, lying flat in bed does not permit the diaphragm to drop by gravity as it does when in the high-Fowler position.

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client?

Suctioning the tracheostomy tube whenever necessary Secretions are increased because of alterations in structure and function; a patent airway must be maintained. The client cannot whisper because air no longer exits the lungs by passing through the vocal cords. Initially nonverbal and written forms of communication are encouraged. The orthopneic position may cause neck flexion and block the airway. The outer tracheostomy tube is not removed because the stoma may close.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear?

Crackles Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?

Tell me more about the conversation you had with your health care provider. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive. Instructing the client to ask the health care provider to clarify the procedure is not the priority; at this point, the nurse should collect more data. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance.

A nurse is preparing a teaching plan for a client with syphilis. The nurse includes that syphilis is not considered contagious in which stage?

Tertiary stage The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes. The primary stage lasts 8 to 12 weeks; the chancre is teeming with spirochetes, and the individual is contagious. The duration of the secondary stage is variable (about five years); skin and mucosal lesions contain spirochetes, and the individual is highly contagious. The incubation stage lasts two to six weeks; spirochetes proliferate at the entry site, and the individual is contagious.

Following the assessment of a child, the nurse concludes that the child has an easy temperament. Which observation in the child supports the nurse's conclusion?

The child is open to changes and adapts positively. The child with easy temperament will respond positively to a new environment and would be open to changes. The difficult child may dislike changes and adapt slowly to new people or a new environment. A difficult child may be highly active, but can be irritable and unpredictable in habits. A child with this type of temperament may also be impatient, may cry often, and throw violent tantrums.

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply.

Checking the child's weight every day Calculating the dose of drug as carefully as possible Assessing the child regularly to help prevent electrolyte loss The child's weight should be checked and recorded daily to aid in the assessment of therapeutic and adverse effects. Pediatric doses should be calculated carefully to prevent an accidental overdose. Pediatric clients are at greater risk of electrolyte loss; therefore, they require closer and more cautious assessment to help prevent hypertension and stroke. Furosemide may cause stomach upset if it is taken on an empty stomach; the child should be given the drug with food to help prevent gastric upset. A child taking diuretics should not be exposed to sunlight for long periods because this action may precipitate fluid volume loss and heatstroke.

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Correct1 Crackles Correct2 Coughing Correct3 Orthopnea 4 Yellow sputum 5 Dependent edema Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.

The nurse auscultates fine crackles in a client who has been in respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the Lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be a very late and fatal sign.

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what?

Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

A nurse is assisting a health-care provider in providing palliative care to a client with lung cancer who has just undergone surgery. The provider instructs the nurse to assist the client with frequent position changes. Which complication is this intervention intended to prevent?

Ineffective airway clearance Clients who undergo lung surgery for the management of lung cancer may have ineffective airway clearance. This problem can be addressed with frequent position changes. Antipyretics and antiemetics should be administered to the client to treat fever and nausea, respectively. To manage fear related to treatment and prognosis, the nurse should monitor changes in the client's communication pattern and expression of feelings such as worthlessness or anxiety. The client should then be encouraged to identify the problem, redefine the situation, obtain needed information, generate alternatives, and focus on solutions.

Clients are encouraged to perform deep-breathing exercises after most types of surgery. The nurse reminds clients that the reason for these exercises is to help do what?

Prevent the buildup of carbon dioxide in the body Retention of carbon dioxide in the blood lowers the pH, causing respiratory acidosis; deep breathing maximizes gaseous exchange, ridding the body of excess carbon dioxide. Deep breathing improves oxygenation of the blood, but it does not stimulate red blood cell production. Although regular deep breathing improves the vital capacity of the lungs, residual volume is unaffected. Deep breathing increases, not decreases, the partial pressure of oxygen.

A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination medication, Rifamate, composed of rifampin (Rifadin) and isoniazid (INH). The nurse evaluates that the teaching regarding the drug is effective when the client says what?

The most important thing I must do is Continue taking the medicine even after I feel better. The medication should be taken for the full course of therapy; most regimens last from six to nine months, depending on the state of the disease. Visual changes are not side effects of this medication. The medication should be taken one hour before meals or two hours after meals for better absorption. Urine or tears turning red-orange is a side effect of rifampin; while this should be reported, it is not an adverse side effect.

An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response?

"Avoid putting your hands near your nose and mouth." Transmission of microorganisms via the hands is one of the most common ways pathogens are transmitted from one person to another. Avoiding putting hands near the nose and mouth interrupts the chain of infection at the portal of entry phase. Staying away from preschool and school-age children is unnecessary and could cause social isolation. However, exposure to these children when they have an active infection should be avoided if possible. Precautions can be taken when around children (e.g., washing the hands, avoiding exposure to nasal and oral secretions). Wearing a sweater under the coat when going outside in cold weather will not limit the exposure to pathogenic microorganisms. However, it may make the person more comfortable because older people have less subcutaneous fat and can be more sensitive to cold environmental temperatures. Colds are caused by viruses; an aspirin will not eliminate these microorganisms. In addition, it is not within the role of a nurse to prescribe medications, even if they are over-the-counter medications.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond?

"That must have really shocked you. Tell me what the healthcare provider told you about it. The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority

Apply a petroleum gauze dressing over the site A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment.

What nursing action will limit hypoxia when suctioning a client's airway?

Apply suction only after catheter is inserted The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?

Chlamydia trachomatis infection Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.

The nurse is reviewing the laboratory reports of a client who has sustained a significant reaction to the tuberculin skin test but has negative findings on bacteriologic studies. The reports further reveal the absence of x-ray findings compatible with tuberculosis (TB) and clinical evidence of TB. Which class of TB does the nurse suspect?

Class 2 In class 2 TB, the client demonstrates a significant reaction to the tuberculin skin test, but bacteriologic studies are negative and there is no clinical or radiographic evidence of TB. The client with class 2 TB has been exposed to latent TB infection but has no disease. In class 0 TB, the client has had no exposure to TB and has negative results on skin testing. In class 1, a client has been exposed to TB but demonstrates no evidence of infection (e.g., a negative result on tuberculin skin testing). In class 3, the client has clinically active TB infection.

A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? Select all that apply.

Correct1 Pneumonia Correct2 Preterm birth 3 Microcephaly Correct4 Conjunctivitis 5 Congenital cataracts Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is what?

Expected, but needs to be addressed Depression is an expected part of grieving that requires supportive care. Although depression is a normal response, intervention is necessary because it cannot be assumed that the depression will be of short duration. Depression is an expected response to the diagnosis of cancer; it does not indicate mental illness. Unless the client is suicidal, immediate acute care is not indicated.

What is the priority goal for a client with asthma who is being discharged from the hospital?

Demonstrates use of a metered-dose inhaler Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have before discharge. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Not all asthma is associated with food allergies.

A health care provider prescribes oxygen given in low concentration rather than in high concentration to a client with chronic obstructive pulmonary disease (COPD). What does this prevent?

Depression of the respiratory center Some clients with COPD must be given only low concentrations of oxygen; decreased oxygen blood level is a major stimulus for breathing for these clients. Prolonged hypoxia stimulates erythrocyte production; the goal of therapy is to relieve hypoxia. The pressure, rather than the concentration, at which oxygen is administered increases the risk of emphysematous bullae rupture. To prevent drying effects on secretions and the mucosa, oxygen may be humidified.

What breathing exercises should the nurse review with a client experiencing emphysema?

Diaphragmatic exercises to improve contraction of the diaphragm With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration which are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

Diminished breath sounds on auscultation Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema.

Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action?

Elevate the head of the bed Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be done eventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Elevate the head of the client's bed and obtain vital signs Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Auscultation of breath sounds should be done also. Discontinuing the IV access line is unsafe and may cause unnecessary discomfort if it must be restarted; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock; assessment for allergies should be done on admission. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply.

Gag reflex Poor dentition Gum retraction The nurse should place a tongue blade along the side of the client's pharynx behind the tonsil and stimulate the gag reflex. Using a good light source, the nurse should inspect the interior of the mouth for poor dentition and gum retraction. These findings may indicate the presence of a respiratory disorder. Polyps may result from a long-term infection of the oral mucosa. The nurse should observe for the presence of polyps during an inspection of the nose. The presence of small, mobile nontender or shotty nodes is not a sign of the pathologic condition.

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client does what?

Has a CD4 + T lymphocyte level of less than 200 cells/micro L. AIDS is diagnosed when an individual with HIV develops one of the following: a CD4 + T lymphocyte level of less than 200 cells/micro L, wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flu-like syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain), one to three weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include?

Helping the client set a date to stop smoking Setting a realistic target date to stop smoking can be motivating because it provides time to gather personal resources while committing to a specific time frame. The American Heart Association and the American Lung Association are appropriate agencies for referral, not the American Red Cross. Increasing eating may result in a weight gain that can precipitate reestablishing the habit of smoking to return to the former weight. The client should be called every three to five days, not weeks, after the target date for optimum support.

A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further information?

I'm upset to know that the tumor may metastasize to my bones." Osteogenic sarcoma is the most common and most often fatal primary malignant bone tumor. It has a high mortality rate because it often is diagnosed after it has metastasized to the lung . Pain may or may not be associated with a primary site or sites of metastasis. Pain that does occur may range from mild and occasional to constant and severe. "I can have metastasis to other parts of my body besides the lung" is a true statement, and further teaching is not necessary. Because the tumor may continue to metastasize, planning for the future (e.g., medical treatment, palliative interventions) should be discussed with the client, family, health care provider, and other support systems.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism

Obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.

A nurse who is caring for a client after head and neck surgery is concerned with the client's anger and depressive episodes about the effects of surgery. Which action indicates the client is reaching acceptance?

Performing self-care of the tracheal stoma The best indicator of acceptance is when the client begins to participate in self-care. Smiling and becoming more extroverted does not indicate acceptance and may be an act of pretended courage. Ambulating in the hall and sitting in the lounge does not indicate acceptance and may be an attempt to relieve boredom. Allowing a family member to participate in care does not indicate acceptance and may indicate dependence.

A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?

Place a surgical mask on the client Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?

Placing a tracheostomy unit by the bedside The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing what?

Respiratory Acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), Hgb, and Hct are related to anemia.

A client recovering from abdominal surgery is encouraged to turn from side to side and engage in deep-breathing exercises. What complication is the nurse trying to prevent?

Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.

A client is receiving oxycodone postoperatively for pain. The health care provider's prescription indicates that the dose should be administered every three hours for eight doses. What should the nurse assess before administering each dose of oxycodone?

Respiratory rate and level of consciousness Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone.

What does the nurse assess for to evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax?

Return of breath sound The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase. Constant bubbling in the water-seal chamber indicates that there is a leak in the closed chest drainage system. Bubbling may occur in this chamber when air exits the pleural space with a cough or forceful expiration; the fluid will rise and fall in this chamber with pleural pressure changes associated with inspiration and expiration (tidaling).

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?

Rises with inspiration and falls with expiration During inspiration, negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration, negative pressure in the pleural space decreases, causing fluid to drop in the chamber. If the system is closed to the atmosphere, as it should be, bubbles will not be present. If the system is closed to the atmosphere, as it should be, bubbles will not be present. Changes in intrapleural pressure cause fluid to rise on inspiration and fall on expiration (tidaling).

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Rubelle Congenital rubella (German measles) syndrome results in abnormalities that vary, depending on the gestational age of the fetus when the maternal infection was contracted; the most severe results occur if the mother was infected during the first trimester, when organogenesis is taking place. Neonatal signs of herpes virus type 2 include fever, coryza, tachycardia, and hemorrhage. Except for microcephaly, the assessments noted by the nurse are not caused by the toxoplasmosis protozoa; this problem is associated with growth retardation, hydrocephalus, chorioretinitis, thrombocytopenia, jaundice, and fever. A chlamydial infection causes neonatal conjunctivitis and pneumonia.

Which nursing action would be appropriate for treating a client with respiratory alkalosis caused by hyperventilation secondary to anxiety? Select all that apply.

Sedating the client Helping the client breath into a paper bag Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body Sedating the client can be beneficial to slow the client's breathing. Asking the client to breathe into a paper bag and/or breathe slowly will help retain and accumulate carbon dioxide in the body. These measures will increase carbonic acid, which will lower the pH level. Mechanical ventilation is only necessary if the metabolic acidosis is severe and the client is comatose. Sodium bicarbonate is a treatment for metabolic acidosis, not metabolic alkalosis.

A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?

Shortness of breath with crackles Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority. Feeling of warmth throughout the body occurs with the IV administration of dye for diagnostic procedures; it does not occur with IV fluids, such as 0.9% sodium chloride (NaCl) or D5W without an additive. Although infiltration at the catheter insertion site may occur, it is not the most serious complication; an altered respiratory status is the priority

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is what?

Sooty The mucous membranes of the respiratory tract may be charred after inhalation burns; this is evidenced by the production of sooty sputum. Frothy sputum usually is indicative of pulmonary edema. Yellow sputum usually is indicative of a respiratory infection. Tenacious sputum usually is indicative of respiratory infection.

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency during the first hours after surgery, what should the nurse do?

Suction as needed After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery. Although the application of an ice collar may limit edema or pain, it will not maintain patency of an airway that is compromised by secretions. A side-lying position will facilitate better drainage from the mouth. The client may not be reactive or have energy to cough or expectorate; the priority is to prevent secretions from entering the respiratory tract.

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately?

Suction the tracheostomy. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube and ties or a healthcare provider changing the tracheostomy tube.

A client with tuberculosis is to begin a medication that combines isoniazid, rifampin, and pyrazinamide, and streptomycin sulfate therapy. The client says, "I've never had to take so much medication for an infection before." What should the nurse explain?

this type of organism is difficult to destroy Multiple drugs are administered because of the concern regarding drug resistance. Streptomycin sulfate is an antibiotic; it does not prevent the side effects of the combination medication. Multiple antitubercular drugs are necessary for an extended period, approximately six to eight months depending on the individual. Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?

turning and positioning Turning and positioning does not require a health care provider's prescription and is an independent action. Postural drainage, administration of an expectorant, and percussion and vibration techniques are dependent nursing functions that require a health care provider's prescription.