Respiratory EAQ

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? 1. Mediastinal shift 2. Tracheal laceration 3. Open pneumothorax 4. Pericardial tamponade

1. Mediastinal shift Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? 1. Remove the air that is present in the intrapleural space 2. Drain serosanguineous fluid from the intrapleural compartment 3. Permit the development of positive pressure between the layers of the pleura 4. Provide access for the instillation of medication into the pleural space

1. Remove the air that is present in the intrapleural space Air rises and is removed via a tube inserted in the upper intrapleural space. Draining serosanguineous fluid from the intrapleural compartment is accomplished by the tube placed at the base of the lung; fluid flows toward the base via gravity. Permitting the development of positive pressure between the layers of the pleura will cause, not prevent, a pneumothorax. Medication will not be instilled into the intrapleural space in this situation.

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room? 1. Suction supplies 2. Writing materials 3. Tracheostomy set 4. Incentive spirometer

1. Suction supplies Suction equipment is the priority. Respiratory complications can occur after a laryngectomy is performed because of the production of excessive secretions, edema of the glottis, or injury to the recurrent laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively to raise secretions.

The oxygen saturation value measured by a pulse oximeter placed on the finger of a client with very dark skin is 95%. What does the nurse infer from this reading? 1. The client has a normal SpO2 value 2. The oximeter is unable to detect desaturation levels 3. The client has an abnormal SpO2 value 4. The oximeter may not work with clients experiencing impaired blood flow

1. The client has a normal SpO2 value Normal pulse oximeter values lie between 95% and 100%. Clients with darker skin normally have slightly lower SpO2 values because of the deeper coloration of the nail bed. A pulse oximeter is indeed able to detect desaturation levels regardless of skin tone. Usually, oximeter values vary with ethnicities because of skin coloration. If a client is having any degree of impaired peripheral blood flow, the oximeter should be placed on the forehead for accurate results.

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? 1. Polycythemia 2. Cor pulmonale 3. Compensated acidosis 4. Left ventricular failure

2. 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 [1] [2] occurs with COPD.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? SATA 1. Vomiting 2. Weight gain 3. Hemoptysis 4. Night sweats 5. Bilateral crackles

3,4 Erosion of lung tissue causes blood in the sputum, a classic sign of tuberculosis. Increased body temperature causes profuse diaphoresis, a classic sign of tuberculosis. Vomiting is associated with a gastrointestinal (GI) obstruction or cancer. Weight loss, not weight gain, is a sign of tuberculosis. Bilateral crackles are associated with excess fluid volume.

A client arrives at a walk-in clinic complaining of chest pain on inspiration and shortness of breath, and has a temperature of 102° F (38.9° C). What term should the nurse document in the medical record when the following is heard on auscultation of the lateral lung fields of this client? Listen to the audio. 1. Stridor 2. Rhonchi 3. Pleural friction rub 4. high-pitched crackles

3. Pleural friction rub A pleural friction rub [1] [2] is a rough, scratching, grating, creaking sound caused by inflamed pleural surfaces rubbing together. It is frequently associated with chest pain. It is most often heard at the end of inspiration and on the beginning of expiration, when the lateral and anterior lung fields are auscultated. A pleural friction rub is associated with pleurisy, tuberculosis, pulmonary emboli, pneumonia, and lung cancer. Stridor is an adventitious breath sound. It is a high-pitched, shrill, harsh sound generally occurring on inspiration, but it can occur on expiration. Depending on its severity, it can be heard on auscultation of the lung or with the naked ear. Stridor occurs with laryngeal obstruction (upper airway obstruction) and is associated with croup syndromes. Rhonchi (gurgles) are adventitious breath sounds. They are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality. Rhonchi indicate partial bronchial obstruction caused by mucus or other fluids in the airway, bronchial hyperreactivity, or the presence of a tumor. High-pitched crackles (rales) are adventitious breath sounds. Crackles are fine, short, interrupted crackling sounds best heard on inspiration, but may be heard on expiration. They are heard on auscultation of the base of the lung as air passes over retained secretions within the alveoli.

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation? 1. Late cyanosis 2. Early tachypnea 3. Late use of accessory muscles 4. Early unexplained restlessness

4. 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.

Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1. Peak expiratory flow rate 2. Forced vital capacity 3. Forced med-expiratory flow rate 4. Forced expiratory volume/forced vital capacity ratio

4. Forced expiratory volume/forced vital capacity ratio Forced expiratory volume/forced vital capacity ratio is useful in differentiating between obstructive and restrictive pulmonary dysfunction. Peak expiratory flow rate aids in monitoring bronchoconstriction in asthma. Forced vital capacity is the amount of air that can be quickly and forcefully exhaled after maximum inspiration. Forced mid-expiratory flow rate is an early indicator of disease of the small airways.

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube? 1. Has an inner cannula 2. Is changed every week 3. Is cleansed once a day 4. Has a low-pressure cuff

4. Has a low-pressure cuff A low-pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis. The tracheostomy tube can be a single-lumen tube or can have inner and outer cannulas. A tracheostomy tube does not have to be changed weekly. The tracheostomy should be cleaned every 8 hours and whenever necessary.

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff? 1. Deflate the cuff before starting each tube feeding 2. Inflate the cuff for one hour before and after each feeding 3. Deflate the cuff after the tube feeding has been completed 4. Inflate the cuff before the feeding and for 30 minutes after each feeding

4. Inflate the cuff before the feeding and for 30 minutes after each feeding Inflating the tracheostomy cuff before and for 30 minutes after each feeding occludes the tracheal lumen around the tracheostomy tube, preventing aspiration if regurgitation occurs. Deflating the tracheostomy cuff before starting a tube feeding will permit aspiration if regurgitation occurs. Although the cuff must be inflated during the tube feeding as well as after to prevent aspiration, it is done just before feeding, not one hour before. Deflating the tracheostomy cuff after the tube feeding has been completed will permit aspiration if regurgitation occurs.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta-blockers 4. Positive end-expiratory pressure (PEEP)

4. Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta-blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.