Respiratory OneDrive
A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
4 mL 1.6/x: 2/5 8=2x x=4
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a MVC. Which of the following should the nurse identify as the priority focus of care? A. Airway protection B. Decreasing intracranial pressure C. Stabilizing cardiac arrhythmias D. Preventing musculoskeletal disability
A. Airway protection
A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign. C. Administer an IV vasopressor medication. D. Monitor the client for headache.
A. Provide high-flow oxygen.
A nurse in the PACU is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases B. Urinary output C. Chest tube drainage D. Pain level
A. Arterial blood gases According to the ABC priority-setting framework, postop sx client may need supp O2 in order to maintain norm blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A. Auscultate lung fields. B. Assess pulse and respirations. C. Assess characteristics of her sputum. D. Instruct to slowly exhale with pursed lips.
A. Auscultate lung fields.
A nurse is assessing the respiratory paern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sittng upright
A. Breathing ranging from very deep to very shallow with periods of apnea
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal.
A. Continue to monitor the client. Fluid in water seal chamber rises 2-4" during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A. Continuous bubbling in the water-seal chamber B. Occasional bubbling in the water-seal chamber C. Constant bubbling in the suction-control chamber D. Fluctuations in the fluid level in the water-seal chamber
A. Continuous bubbling in the water-seal chamber
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level B. Decreased level of serum lipids C. Decreased erythrocyte sedimentation rate (ESR) D. Increased platelet count
A. Decreased serum calcium level
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations
A. Dyspnea C. Barrel chest D. Clubbing of the fingers Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow.
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A. Respiratory acidosis
The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion. B. Check pupillary response to light. C. Assess the capillary refill. D. Check client's response to questions about place and time.
A. Evaluate chest expansion.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C. Increased blood pressure from 112/68 to 120/72 mm Hg. D. Increased heart rate from 68 to 72/min.
A. Increased respiratory rate from 18 to 44/min.
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? A. Lethargy B. High-grade fever C. Weight gain D. Dry cough
A. Lethargy
A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds
A. Loud, scratchy sounds
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.) A. Rifampin B. Isoniazid C. Acyclovir D. Pyrazinamide E. Montelukast
A. Rifampin B. Isoniazid D. Pyrazinamide
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? A. Withhold food and liquids until the client's gag reflex returns. B. Irrigate the client's throat every 4 hr. C. Have the client refrain from talking for 24 hr. D. Suction the client's oropharynx frequently
A. Withhold food and liquids until the client's gag reflex returns.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.
B. Administer oxygen therapy.
A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following? A. 300 mL B. 480 mL C. 800 mL D. 950 mL
B. 480 mL The average tidal volume is 7-9 mL/kg. 60 kg x 8 mL/kg = 480. Therefore, this setting is within the average range.
A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? A. Insert an oral airway. B. Administer the abdominal thrust maneuver. C. Turn the client to the side. D. Perform a blind finger sweep.
B. Administer the abdominal thrust maneuver. Nurse should immed begin applying abdominal thrusts to a conscious pt who has airway obstruction and should continue until obstruction is clear or pt loses consciousness.
A nurse is caring for a client who is 12 hr postop and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber B. Continuous bubbling in the water-seal chamber C. Bloody drainage in the collection chamber D. Fluid-level fluctuations in the water-seal chamber
B. Continuous bubbling in the water-seal chamber
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? A. Insert an IV line. B. Count the respiratory rate. C. Administer oxygen. D. Prepare equipment for intubation.
B. Count the respiratory rate. Checking the client's respiratory status is the priority action when following the nursing process approach to client care. The nurse should admin O2 to pt using a high-flow, non-rebreather mask to prevent hypoxia. However, it isn't priority action when following nursing process approach to pt care.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10
B. Difficulty swallowing
A nurse in the emergency department is caring for a client who was injured in a motorvehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis B. Flail chest C. Hemothorax D. Pneumothorax
B. Flail chest
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub
B. Increasing dyspnea
A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? A. Clamp the tube when the client is ambulating. B. Keep the collection device below the level of the client's chest. C. Coil the tubes carefully to prevent kinking. D. Lay the client flat to avoid leaks in the tubing.
B. Keep the collection device below the level of the client's chest.
A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect? A. Dullness B. Resonance C. Tympany D. Flatness
B. Resonance
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension
C. Agitation
A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. B. Assess for an increase in temperature. C. Check the oximeter. D. Monitor for manifestations for increased intracranial pressure.
C. Check the oximeter. Priority action nurse should take when using ABC approach to pt care is to maintain patent airway. Checking oximeter is the first indicator of poor O2 exchange which can cause cerebral edema.
A nurse is caring for a client who just developed a pulmonary embolism. Which of the following meds should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine
C. Heparin
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature
C. Increased heart rate Pts are at risk for devel pulm edema/CV distress d/t mediastinal content shift after aspiration of lrg amt of fluid from pt's pleural space. So,, pt may experience increased HR & RR, and coughing with blood-tinged frothy sputum, and tightness in chest. These require notification of HCP immed.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times. D. Empty the collection chamber prior to transport.
C. Keep the drainage system below the level of the client's chest at all times.
A nurse in the PACU is assessing a client who has an ET tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. Movement of the ET tube into the right main bronchus D. Infection of the vocal cords
C. Movement of the ET tube into the right main bronchus
A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect? A. Petechiae on the chest and the abdomen B. WBC 16,000/mm3 C. Negative throat culture D. Severe hyperemia of pharyngeal mucosa
C. Negative throat culture A client who has viral pharyngitis will have a negative throat culture. A client who has bacterial pharyngitis usually has a throat culture positive for beta-hemolytic streptococcus.
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning
C. Performing the procedure independently
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C. Respiratory acidosis With uncompensated respiratory acidosis, pH is less than 7.35 and PaCO2 is greater than 45 mm Hg.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? A. Pertussis B. Mycoplasma pneumonia C. Tuberculosis D. Respiratory syncytial virus
C. Tuberculosis
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.
D. Administer oxygen via nasal cannula.
A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion
D. Confusion
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Continue to monitor the client's respiratory status.
D. Continue to monitor the client's respiratory status.
A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? A. Intracranial pressure B. Spinal cord perfusion C. Renal function D. Hemodynamic status
D. Hemodynamic status
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care? A. Patency of the intravenous line. B. Level of pain. C. Integrity of the dressing. D. Need for suctioning.
D. Need for suctioning.
A nurse is developing a plan of care for a client who is 12 hr postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications? A. Use incentive spirometer every 4 hr while awake. B. Initiate ambulation after discontinuing the NG tube. C. Maintain supine position with abdominal binder. D. Splint the incision to support coughing every 2 hr.
D. Splint the incision to support coughing every 2 hr.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another nonsurgical client C. A room in the ICU D. A room that is within view of the nurses' station
A. A room with air exhaust directly to the outdoor environment
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
A. Airway obstruction
A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? A. Bag valve mask device B. Defibrillator machine C. Chest tube equipment D. Central venous catheter tray
A. Bag valve mask device A bag valve mask device is required next to bedside for a pt who has received a competitive NM blocking agent to prov vent support in case pt develops resp arrest. Competitive NM blocking agents relax skeletal muscles and can cause temp paralysis of diaphragm.
A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions? A. Carbon monoxide poisoning B. Heat stroke C. Hypersensitivity reaction D. Oxygen toxicity
A. Carbon monoxide poisoning
The nurse is caring for a postop client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? A. Fluctuation of the fluid level within the water seal chamber B. Absence of fluid in the drainage tubing C. Continuous bubbling within the water seal chamber D. Equal amounts of fluid drainage in each collection chamber
A. Fluctuation of the fluid level within the water seal chamber Fluctuation of fluid within the water seal chamber occurs with inspiration and expiration until the client's lungs have re-expanded or the system is occluded. Bubbling w/in H2O seal cham is norm during forceful exp/coughing. Contin bubbs indics air leak.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side B. Bubbling of the water in the water seal chamber with exhalation C. Crepitus in the area above and surrounding the insertion site D. Eyelets are not visible
A. Movement of the trachea toward the unaffected side
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) A. Night sweats B. Low-grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum
A. Night sweats B. Low-grade fever E. Blood in the sputum
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A. Oral mucosa B. Conjunctivae C. Soles of feet D. Ear lobes
A. Oral mucosa
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A. Poor impulse control B. Unable to discriminate words and letters C. Deficits in the right visual field D. Motor retardation
A. Poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.
A nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax. Which of the following is appropriate to include in the plan of care? A. Provide respiratory support. B. Place the client in droplet isolation. C. Administer antihypertensive medications. D. Monitor ascites.
A. Provide respiratory support.
A nurse is caring for a client who is postoperave and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A. Respiratory acidosis
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) A. Severe dyspnea B. Nausea C. Decreased level of consciousness D. Headache E. Hypotension
A. Severe dyspnea C. Decreased level of consciousness D. Headache E. Hypotension
A nurse is caring for a client who is postoperative following an intermaxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside? A. Wire cutters B. NG tube C. Urinary catheter tray D. IV infusion pump
A. Wire cutters
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."
B. "I will take my bronchodilators after meals." Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.
A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? A. "Check your heart rate before each dose." B. "Inspect your mouth for lesions daily." C. "Use this medication to relieve an acute attack." D. "Skip the morning dose if you do not have any symptoms."
B. "Inspect your mouth for lesions daily."
A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? A. "Eat 3 large meals each day." B. "Limit water intake with meals." C. "Reduce protein intake." D. "Use a bronchodilator 1 hour before eating."
B. "Limit water intake with meals." The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.
A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? A. Raise the affected extremity above the level of the heart. B. Immobilize the affected extremity with a splint. C. Apply ice to the bite area. D. Apply a tourniquet to the affected extremity.
B. Immobilize the affected extremity with a splint.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest
B. Increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.
A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position? A. Lateral segment of the left lower lobe B. Lateral segment of the right lower lobe C. Posterior segment of the right middle lobe D. Posterior segment of the right lower lobe
B. Lateral segment of the right lower lobe The nurse would position the client in a left lateral Trendelenburg position (head lower than feet) to help drain the lateral segment of the right lower lobe.
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. HCO3- 30 mEq/L B. PaCO2 50 mm Hg C. pH 7.45 D. Potassium 3.3 mEq/L
B. PaCO2 50 mm Hg
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A. Confusion B. Weakness C. Increased intracranial pressure D. Paralytic ileus
B. Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia. B. hoarseness. C. dyspnea. D. weight loss.
B. hoarseness.
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A. Kussmaul respirations B. Apneustic respirations C. Cheyne-Stokes respirations D. Stridor
C. Cheyne-Stokes respirations
A nurse is monitoring an older adult client immediately following a bronchoscopy. Nurse's priority is to mon client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C. Confirming the gag reflex
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a MVC. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Perform a Glasgow Coma Scale assessment. B. Establish IV access. C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. E. Remove clothing for a thorough assessment
C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. B. Establish IV access. A. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment
A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with an emesis basin. B. Notify housekeeping. C. Prevent the client from aspirating. D. Administer an antiemetic to the client.
C. Prevent the client from aspirating.
A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include? A. "Take isoniazid with an antacid." B. "Provide a sputum specimen every 2 weeks to the clinic for testing." C. "Expect your sputum cultures to be negative after 6 months of therapy." D. "Drink at least 8 ounces of water when you take the pyrazinamide tablet."
D. "Drink at least 8 ounces of water when you take the pyrazinamide tablet." A client who has TB usually takes pyrazinamide for first 2 months of therapy and can shorten the entire course of therapy to 6 mos. Nurse should instruct client to drink at least 240 mL (8 oz) of fluid when taking the med and to protect himself from sun with cotton clothing and sunscreen.
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn via metered-dose inhaler B. Montelukast orally C. Budesonide via dry-powder inhaler D. Albuterol via jet nebulizer
D. Albuterol via jet nebulizer
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel
D. Barrel
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily
D. Encouraging the client to drink 2 to 3 L of water daily
A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? A. Bowel sounds B. Surgical dressing C. Temperature D. Oxygen saturation
D. Oxygen saturation
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? A. Position the head of the client's bed in the flat position. B. Turn the client every 4 hr. C. Rinse the client's mouth with an antimicrobial solution every 4 hr. D. Perform hand hygiene prior to suctioning the client's endotracheal tube.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning.
D. Perform pre-oxygenation prior to suctioning. Suctioning should be performed on the ET tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. In prep for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.) Decreased lung sounds. HR 110 and reg SQ emphysema.
Decreased lung sounds is correct. Decreased lung sounds on the affected side can indicate a pneumothorax. This finding requires immediate f.u. with HCP. HR 110 and reg is correct. A HR within the expected range is 60 to 100/min. Tachycardia is a manifestation of a possible pneumothorax. SQ emphysema is correct. It's an abnorm find which represents presence of air in tissue layers of skin. This can indica persistent air leak caused by a puncture that tears the pleura. This finding requires immed f.u. with client's HCP. Incorrect: O2 sat of 95% is incorrect. An O2 sat equal to or greater than 95% is within expected ref range and doesn't require immediate f.u. with HCP. Trachea midline is incorrect. During neck assessment, trachea should be midline above suprasternal notch. So, this finding doesn't require immed f.u. with pt's HCP. Puncture site dry is incorrect. Insertion site and dressing should be clean, dry, and intact. Therefore, this finding does not require immediate follow-up with the client's provider.
Select the 5 findings that require follow-up. a. Disorientation b. Barrel chest c. Ankle edema d. Yellow sputum e. SaO2 92% f. Nebulizer use g. Live alone h. Finger clubbing
Disorientation is correct. Changes in orientation can indicate hypoxia or other pathologies. a. Disorientation c. Ankle edema d. Yellow sputum f. Nebulizer use g. Live alone
Complete the following sentence by using the list of options. Dropdown 1Place the client in high-Fowler's position is correct.
Dropdown 1Place the client in high-Fowler's position is correct.
A nurse prioritizes care after completing the assessment and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Nurse should identify that pt is potentially experiencing an air leak bc there's contin bubbling in water seal chamber of chest drainage sys. N should assess for SQ emphysema by palpating around dressing site. If SQ emphysema is present, nurse will hear cracking sound with palpation, and HCP should be notified. Nurse should also check drainage sys and tubing for source of air leak. If leak is found in drainage sys, the unit should be replaced. If nurse can't find source of air leak w/in the drainage unit, HCP should be notified. Nurse should mon pt for their ability to perform lung expansion exercises, such as deep breathing, use of an incentive spirometer, and coughing. These will help to maximize client's lung inflation, open closed airways, and remove secretions. Nurse should also mon the pt's resp status. If pt is experiencing air leak, a pneumothorax is possible. Pt will exhibit tachycardia, tachypnea, and increasing SOB. Pneumothorax is a med emergency, and HCP should be notified immediately
The nurse is reviewing the client's data to prepare the client's plan of care.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Nurse should request a D-dimer and apply O2 bc pt is most likely experiencing PE bc has had a sudden onset of dyspnea with pleuritic (sharp) chest pain along with hypotension after returning from a trip. Due to a decreased gas exchange, pt needs O2 applied. D-dimer needs to be drawn to assist with diagnosing a PE. Nurse should mon pt's pulse ox and partial thromboplastin time bc a pt who's had a PE display manifestations of decreased gas exchange and decreased tissue perfusion. Tx for PE includes drug therapy with an anticoag, such as unfractionated heparin, LMW heparin, or fondaparinux. Pt's partial PTT is drawn before anticoag therapy starts & throughout therapy per facil policy.
A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Obtain ABGs is anticipated. ABGs should be obtained to further assess pt's resp status. Prep for insertion of chest tube is anticipated. Chest tubes are inserted into a pt who has a pneumo to re-expand the lung. Obtain IV access is anticipated. IV access is anticipated to admin meds for chest tube insertion, as well as for emergency vascular access, if needed. CT of chest is nonessential. Pt's pneumo takes priority bc it compromises gas exchange. CT scan may be done after pt is stabilized following chest tube insertion. Pulmonary Function Tests are nonessential. PFTs are used for screening and measuring lung vols and capacities. This isn't appropriate at this time; delaying tx of pneumo could cause harm to pt. Thoracentesis is contraindicated. Thoracentesis is used to aspirate air or fluid from the pleural space but does not restore lung expansion.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should apply supplemental oxygen to the client and prepare to initiate thrombolytic therapy because the client is most likely experiencing a pulmonary embolus. The client has a warm reddened area on their calf and is experiencing dyspnea and hypoxia. The nurse should monitor the client's oxygen saturation to assess the client's respiratory status and monitor the client's coagulation studies to regulate anticoagulation and reduce the risk for bleeding.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should plan to administer a bronchodilator and measure the client's peak airflow because the client is most likely experiencing asthma. The nurse should monitor the client's pulmonary function tests and oxygen saturation to assess the client's progress and determine the need for supplemental oxygen.
Select the 3 findings from day 3 that require immediate follow-up. WBC, respirations, temp
WBC count is correct. Client's WBC count is greater than the expected reference range, indicating an infection. Therefore, this finding requires immediate follow-up. Respirations is correct. Tachypnea and a decreased oxygen saturation could indicate potential respiratory distress. Therefore, this finding requires immediate follow-up. Temp is correct. Pt's temp is greater than expected ref range, indicating an infxn. Therefore, requires immediate f.u. Incorrect: Hct level is incorrect. The client's hct level is within the expected reference range and does not require follow-up. Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up.
A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A. Administer high-flow oxygen at 5 L/min by facemask to the client. B. Place the client in high-Fowler's position with legs dependent. C. Give the client sublingual nitroglycerin. D. Reassure the client.
A. Administer high-flow oxygen at 5 L/min by facemask to the client.
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A. Carvedilol B. Fluticasone C. Captopril D. Isosorbide dinitrate
A. Carvedilol Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.
A nurse is caring for a client who was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer? A. Ciprofloxacin B. Fluconazole C. Tobramycin D. Vancomycin
A. Ciprofloxacin Ciprofloxacin, a fluoroquinolone, is the antibiotic of choice to treat and prevent systemic infection with Bacillus anthracis.
A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (Select all that apply.) A. Ciprofloxacin B. Doxycycline C. Amoxicillin D. Penicillin G E. Cefotaxime
A. Ciprofloxacin B. Doxycycline C. Amoxicillin
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? A. Propranolol B. Theophylline C. Montelukast D. Prednisone
A. Propranolol Meds that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.
A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat
A. Stridor
A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect? A. Widened QRS complexes B. Hyperactive deep tendon reflexes C. Bounding peripheral pulses D. Warm, flushed skin
A. Widened QRS complexes A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block.
A nurse is caring for a female client in the ED who reports SOB and pain in the lung area. She states that she started taking birth control pills 3 wks ago and that she smokes. Her HR is 110/min, RR 40/min, and BP 140/80. ABGs are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which is the priority nursing intervention? A. Prepare for mechanical ventilation. B. Administer oxygen via face mask. C. Prepare to administer a sedative. D. Assess for indications of pulmonary embolism.
B. Administer oxygen via face mask. pH reflects alkalosis, and low PaCO2 indicates lungs are involved, so client has respiratory alkalosis. Client's O2 sat is low, so one priority is to admin O2 via mask attempting to achieve an O2 sat of at least 95%. Greatest risk to client is hypoxia, thus the priority is to restore oxygenation
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.
C. Preoxygenate the client with 100% oxygen for up to 3 min. To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.
A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care? A. Use aseptic technique. B. Clean the inner cannula with mild soap and water. C. Secure new tracheostomy tubes before removing old ones. D. Apply suction when inserting the catheter.
C. Secure new tracheostomy tubes before removing old ones. Tube dislodgement and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying new ties, the nurse can secure the tube and prevent dislodgement.
A nurse is teaching a client who is obese and has obstrucve sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
D. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.
D. Instruct the client to use pursed-lip breathing.
A nurse is assessing a client who has postop atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions
D. Intercostal retractions Hypoxia is condition in which body tissues are O2-starved. Follows hypoxemia low O2 in blood) and is manifested as substernal/intercostal retracns as body works harder to draw more O2 into lungs. Clients who have hypoxia gen have rapid, shallow respirations and are dyspneic, not bradypneic. The client who is hypoxic is increasingly restless, not lethargic, and may state feeling light-headed.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? A. Hypoglycemia B. Hypertension C. Polyuria D. Oral candidiasis
D. Oral candidiasis
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has L-sided HF and has a BNP level of 600 pg/mL. C. The client who has end-stage renal failure and is sched for dialysis today. D. The client who has gastroenteritis and is febrile.
D. The client who has gastroenteritis and is febrile. This client has two risk factors for the devel of fluid vol def, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a sig source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fl vol def.
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% B. No fluctuations in the water seal chamber C. No reports of pleuritic chest pain D. Occasional bubbling in the water-seal chamber
B. No fluctuations in the water seal chamber Fluctuation stops when lung has re-expanded, but nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, bc fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of tubing, or suction source isn't functioning.
A nurse is caring for a client who is 1-day postoperative following a le lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
C. Verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."
C. "I will follow a daily diet high in calories and protein." Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration. B. Ensure adequate nutrition. C. Promote oral hygiene D. Relieve the client's pain.
A. Prevent aspiration.
A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A. Instruct the woman to call 911. B. Ask the partner if he can speak. C. Use the jaw-thrust maneuver. D. Perform chest compressions.
B. Ask the partner if he can speak. Before intervening, nurse should determine if the partner's airway is blocked. Therefore, the nurse should ask the partner if he can speak. If he can speak, breathe, or cough, air is moving through his airway.
A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." B. "Use the incentive spirometer every 4 hr after the tube is removed." C. "Avoid speaking for long periods." D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed."
C. "Avoid speaking for long periods." The client should avoid speaking for long periods to promote gas exchange. To reduce the risk of respiratory distress after the tube is removed, the nurse will monitor the client's vital signs every 5 min (not 15 min) after the tube is removed.
A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? A. Bradycardia B. Night sweats C. Confusion D. Narrowed pulse pressure
C. Confusion
A nurse is developing a plan of care for a client who is postop. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant
C. Encourage the use of an incentive spirometer
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A. Maintenance of ideal weight B. Annual influenza immunization C. Smoking cessation D. Regular moderate exercise
C. Smoking cessation
A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport B. A client who has a prescription for discharge C. A client who received oral pain medication 30 min ago D. A client who told an assistive personnel he is short of breath
D. A client who told an assistive personnel he is short of breath
A nurse is teaching a client who will undergo a bronchoscopy procedure. The provider will use a rigid scope and general anesthesia. The nurse should explain that the client's neck will be in which of the following positions? A. A flexed position B. An extended position C. A neutral position D. A hyperextended position
D. A hyperextended position
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Administering a nebulized beta-adrenergic
D. Administering a nebulized beta-adrenergic The greatest risk to the pt's safety is airway obstruction. Beta-adrenergic meds act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A. Pain severity B. Wound drainage C. Tissue integrity D. Airway patency
D. Airway patency
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) A. Elevate the head of the bed to at least 30°. B. Verify the prescribed ventilator settings daily. C. Apply restraints if the client becomes agitated. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily.
A. Elevate the head of the bed to at least 30°. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth Elevate the head of the bed to at least 30° is correct. A client who is intubated is at risk for aspiration and ventilator-associated pneumonia. To minimize these risks, the nurse should maintain the head of the bed at 30° or higher. Administer pantoprazole as prescribed is correct. Stress ulcers occur in many patients receiving mechanical ventilation. Antacids, histamine blockers, or proton-pump inhibitors are often prescribed as soon as a client is intubated. Reposition the endotracheal tube to the opposite side of the mouth daily is correct. The nurse should assess the area around the endotracheal tube frequently for color, tenderness, skin irritation, and drainage. The nurse should perform oral care every 2 hr. To prevent skin breakdown, the oral endotracheal tube should be moved to the opposite side on the mouth once daily Incorrect Verify the prescribed ventilator settings daily is incorrect. The nurse should perform and document ventilator checks at least every 8 hr to ensure the ventilator settings are as prescribed. Apply restraints if the client becomes agitated is incorrect. A client who becomes agitated or restless might be experiencing air hunger. The nurse should assess the flow settings. If the client continues to be restless or agitated, a chemical restraint, such as midazolam, may be administered. Physical restraints are a last resort and only applied to prevent accidental dislodgement of the endotracheal tube.
A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.) A. Inhale deeply and then exhale completely. B. Place her lips firmly around the mouthpiece. C. Breathe in deeply over 2-3 seconds while pushing down on the canister. D. Hold her breath for 10 seconds. E. Exhale slowly through pursed lips. F. Wait 60 seconds between each puff.
A. Inhale deeply and then exhale completely. B. Place her lips firmly around the mouthpiece. C. Breathe in deeply over 2-3 seconds while pushing down on the canister. D. Hold her breath for 10 seconds. E. Exhale slowly through pursed lips. F. Wait 60 seconds between each puff.
A client is admitted to the emergency room with a respiratory rate of 7/min. ABGs reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22. PaCO2 68 mm Hg. Base excess -2. PaO2 78 mm Hg. Saturation 80% Bicarbonate 26 mEq/L. A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis
A. Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of resp func. It can be the result of resp depression, seen with anesthesia or opioid admin; inadequate chest expansion, due to a weakness of the resp muscles or constriction to the thorax; an obstr of the airway, seen in aspir, bronchoconstriction, or laryngeal edema; or from an inabil of lungs to adeq diffuse gases (O2/ CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. ABGs will reveal a pH lower than norm ref range (7.35 - 7.45) and a CO2 level that is higher than norm reference range (35 - 45 mm Hg).
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.) A. The student should use his quick-relief inhaler. B. The student's asthma is not well controlled. C. The student's peak flow is 50% to 80% of his best peak flow. D. The student needs to go to the hospital. E. The nurse should obtain a second expiratory flow rate.
A. The student should use his quick-relief inhaler. B. The student's asthma is not well controlled. C. The student's peak flow is 50%-80% of his best peak flow. E. The nurse should obtain a second expiratory flow rate.
A nurse is caring for a client who is postop following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is priority for the nurse to make? A. "We can teach you some relaxation techniques to minimize your pain." B. "Keep wire cutters with you at all times." C. "Use a water pick device to keep your teeth clean." D. "Consume a high-protein, liquid diet."
B. "Keep wire cutters with you at all times." When using the ABC approach to client care, nurse should determine that priority info to include is to tell client to keep wire cutters available at all times. When jaw is wired shut, pt is likely to aspirate if vomiting occurs. Client should use wire cutters to clip wires to keep mouth clear of emesis, and should notify provider so the jaw can be re-wired.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. Increase the oxygen flow to 3 L/min. B. Assess the client's respiratory status. C. Call emergency services for the client. D. Have the client cough and expectorate secretions.
B. Assess the client's respiratory status. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count.
B. Inspect the mouth for signs of inhalation injuries. Burn injuries that exceed 20% of body surface area are considered major burns, which affect the pt's metabolism, hemodynamic balance, and immune system. In the early stage of burns, increased capillary permeability allows Na to enter cells while K leaks out, resulting in hypoNa & hyperK. An altered osmotic gradient and loss of intravascular fluid causes elev hematocrit levels. Initial lab studies are imp to create a baseline because of these systemic effects of burns. Those labs would include a CBC, electrolytes, BUN, creatinine, and BG. While it is important to establish baseline data, another action is the priority.
A nurse is providing teaching to a client who is postoperative following CABG surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.
B. It facilitates the client's deep breathing. When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? A. Chest tube eyelets not visible B. Continuous bubbling in the suction control chamber C. Presence of tidal fluctuation in the water seal chamber D. Development of subcutaneous emphysema
D. Development of subcutaneous emphysema Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.
A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily
D. Encouraging the client to drink 2 to 3 L of water daily
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.
D. Place in a prone position. Oxygenation in pts w/ ARDS is improved when placed in prone. Freq and consistent turning of pt is also beneficial and can be accomplished by use of specialty beds. ARDS is an acute RF in which client remains hypoxic despite admin of 100% oxygen. Clients who have ARDS require high concentrations of oxygen, usually by mask or ventilator.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction. B. Strip the client's chest tube. C. Clamp the client's chest tube. D. Reposition the client.
D. Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from chest tube. Nurse increasing wall suction doesn't affect amt neg pressure of CT and wouldn't relieve burning.
