respiratory evolve

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? Auscultate the chest Obtain the vital signs Elevate the head of the bed Position the client on the right side

Elevate the head of the bed

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. Change the dressing daily using aseptic technique. Empty the drainage chamber at the end of the shift.

Palpate the surrounding area for crepitus.`

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? They are indicative of pleural rubbing. They are signs of bronchial constriction. Crackles are located in the smaller air passages. Crackles are heard during respiratory expiration.

Crackles are located in the smaller air passages.

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? "I will use only grounded electrical equipment." "I have a new woolen blanket to keep me warm." "I have told my family they cannot smoke in the house." "I will keep a pitcher of water near me so I drink enough."

"I have a new woolen blanket to keep me warm."

A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply. "I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately." "I'll report any decrease in heart rate immediately." "I'll call you right away if my nagging cough disappears." "I'll call you right away if my shallow breathing goes away."

"I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately."

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 5-mm erythema with no induration No erythema with 3-mm induration 7-mm erythema with 5-mm induration 5-mm erythema with 10-mm induration

5-mm erythema with 10-mm induration

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? A nursing diagnosis An inaccurate interpretation A correct nursing assessment An accurate conclusion if crepitus was ruled out

An inaccurate interpretation

Which pulmonary risk may be increased in a postoperative client due to anesthesia? Rhonchi Fremitus Dyspnea Atelectasis

Atelectasis

`The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. Which immediate action should the nurse take? Weigh the client Auscultate breath sounds Obtain arterial blood gases Turn the client on the right side

Auscultate breath sounds

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? Cardiac problems Joint inflammation Kidney dysfunction Peripheral neuropathy

Cardiac problems

A nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions? Increase oral fluid intake Provide chest physiotherapy Humidify the prescribed oxygen Instill a saturated solution of potassium iodide

Humidify the prescribed oxygen

A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? Change in level of consciousness Increased pain Increased respiration Decreased heart rate

Increased respiration

A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take? Inspect the dressing Increase the oxygen flow rate Notify the healthcare provider Place the client in the supine position

Inspect the dressing

A client with a sucking chest wound has a large, tight dressing over the site. Which purpose of the dressing does the nurse consider when planning care for this client? Protects the lung Seals off major vessels Prevents additional contamination of the wound Maintains the appropriate pressure within the chest cavity

Maintains the appropriate pressure within the chest cavity

The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results? Influenza virus Diphtheria bacillus Bordetella pertussis Mycobacterium tuberculosis

Mycobacterium tuberculosis

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished? Neutral pressure in the pleural space Negative pressure in the pleural space Atmospheric pressure in the thoracic cavity Intrapulmonic pressure in the thoracic cavity

Negative pressure in the pleural space

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? Turn the client onto the right side Notify the healthcare provider immediately Document the output as an expected finding Irrigate the drainage catheter to ensure patency

Notify the healthcare provider immediately

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? Productive coughing Return of breath sounds Increased pleural drainage in the chamber Constant bubbling in the water-seal chamber

Return of breath sounds

In which positions should the nurse place a client who has just had a right pneumonectomy? Right or left side-lying High-Fowler or supine Supine or right side-lying Left side-lying or low-Fowler

Supine or right side-lying

During data collection, the nurse inspects the client's nose and concludes that the client has an infection. Which finding supports the nurse's conclusion? Bloody discharge Watery discharge Thick mucosal discharge Purulent and malodorous discharge

Thick mucosal discharge

A nurse is caring for a client who had a bronchoscopy one hour ago. Which nursing action is most appropriate for assessing the return of the client's gag reflex? Ask the client to say several words. Give the client a small swallow of water. Stroke the anterior third of the client's tongue. Touch the client's pharynx with a tongue depressor.

Touch the client's pharynx with a tongue depressor.

What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord? Crash cart with bed board Airway and rebreathing mask Tracheostomy set and oxygen Ampule of sodium bicarbonate

Tracheostomy set and oxygen

The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. Verify breath sounds. Encourage deep breaths. Observe for signs of pneumonia. Ensure a chest x-ray is performed after the procedure. Instruct the client to cough during the procedure.

Verify breath sounds. Encourage deep breaths. Ensure a chest x-ray is performed after the procedure.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How should the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds

Vesicular breath sounds