Respiratory: Saunders NCLEX Review, Alterations in Respiratory Function, Pulmonary Disorders Medications, Respiratory Disorders, Asthma, and COPD.
Crackles
- "Clicking, rattling, popping sounds" - Sound of air moving through fluids in lungs - Heard in pts w/ pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis
Sinusitis: Symptoms
- Acute: Significant pain, purulent nasal drainage, nasal obstruction, congestion, fever, malaise - Chronic: Facial pain, nasal congestion, increased drainage; severe pain and purulent drainage are often absent - Symptoms may mimic those seen with allergies - Difficult to diagnose because symptoms may be nonspecific; patient is rarely febrile
Laryngectomy Interventions
- Maintaining a patent airway - Position in Fowler's or semi-fowler's - Deep breath & coughing - Regular cleaning of laryngectomy tube - Promoting adequate nutrition - May be NPO for 10-14 days > TPN or enteral feeds - Good mouthcare, decreased taste & smell - Promoting alternative communication methods - Will need call bell @ all times - May use talking board or pen & paper
Fibrosis
- Thickening & scarring of connective tissue, usually resulting from injury
Bronchoscopy
- Used to view bronchial tree and to remove foreign obstructions, obtain tissues for biopsy, or for suctioning fluid - Bronchoscope inserted into pt's mouth and down trachea and bronchial tree.
Vital Capacity
- Max amount of air exhaled after max inspiration
Inspiratory Force
- Measure of pressure needed to inhale
Airway Obstruction
- May be complete or partial - Complete obstruction is a medical emergency. - Partial obstruction may occur as a result of aspiration of food or a foreign body; laryngeal edema following extubation; laryngeal or tracheal stenosis; CNS depression; or allergic reactions.
Lung Cancer
- Uncontrolled cell growth in lung tissues leading to tumor - Tobacco is #1 cause but is also caused by asbestos, mustard gas, wood dust, cement dust, tar products & metals - Diagnosed with laryngoscope & biopsy, CT & MRI can also be used
Chest X-Ray
- Used to assess size and position of heart and lungs - Looking at lung density and assessing for abnormal accumulation of fluid in lungs
Influenza
- Viral infection affecting respiratory tract which spreads through droplets - Infection can settle in upper or lower respiratory tract and causes damage to the upper layers of cells - Can lead to pneumonia - In mild cases symptoms can dissipate within 7 days
Pleuras of Lungs
- Visceral Pleura- Close to lungs - Parietal Pleura - Close to chest wall - Pleural space between the two layers containing small amount of fluid to prevent friction w/ chest movement on inspiration & expiration
Alevoli
- Air-filled sacs containing membranes coated w/ surfactant (Helps alveoli to expand evenly & prevents collapse) - CO2 & O2 are exchanged, higher concentration of gas moves to lower area of concentration - High CO2 in the blood moves into alveoli and is expired by lungs - High O2 in alveoli crosses membrane and attaches to hemoglobin and is distributed through the body
Tidal Volume
- Amount of air volume in lungs which is displaced between inhalation and exhalation - Approximately 500mL
Pulse Oximetry
- Amount of oxygen saturating hemoglobin molecules - Normal value = 95-100%
Pharyngitis: Treatment
- Anti-infectives for bacterial, symptomatic for viral, anti-histamine for allergy - Infection control - Symptomatic relief - Prevention of secondary complications
Reasons for Tracheotomy
- Bypass upper airway obstruction - Facilitate removal of secretions - Long-term mechanical ventilation - Permit oral intake and speech in patient who requires long-term mechanical ventilation
Nasal Obstruction
- Caused by polyp or deviated septum - Usually treated w/ minor surgery
Atelectasis Nursing Interventions
- Chest physio - May need bronchodilator - Encourage deep breathing and coughing, frequent turning and incentive spirometry
Acute Viral Rhinitis
- Common cold or acute coryza - Caused by viruses that invade the upper respiratory tract; spread by airborne droplet sprays emitted while breathing, talking, sneezing, or coughing or by direct hand contact
Peritonsillar Abscess
- Complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils - Tonsils may enlarge sufficiently to threaten airway patency - Patient experiences a high fever, leukocytosis, and chills
Lungs
- Contained within pleural sac in thoracic cavity which operates on negative pressure
Lung Cancer: Symptoms
- Cough - Hemoptysis - Anorexia - Fatigue - Dyspnea - Chest pains
Pigeon Chest
- Deformed chest w/ projecting breastbone
Funnel Chest
- Deformed chest w/ sunken breastbone
Lung Cancer: Treatment
- Depends on extent of tumor - Usually surgery & radiation are the first steps - Sometimes micro laryngeal surgery can be performed in early stages - Chemotherapy is used if there is a recurrence
Arterial Blood Gases
- Determines pt's ventilation, tissue oxygenation, & acid-base status - Assess for normal values • pH 7.35-7.45 • PaO2 80-100 mmHg • PaCO2 35-45 mmHg • HCO3 22-26 mEq/L
Pneumonia: Symptoms
- Dypsnea - Fever/chills - Cough - Crackles - Colored sputum - Tachycardia - Tachypnea - Headache - Muscle & joint pain
Atelectasis: Symptoms
- Dyspnea - Anxiety - Tachypnea - Diaphoresis - Cyanosis - Hypoxemia
Sinusitis: Treatment
- Environmental control - Appropriate drug therapy - Increase fluid intake - Nasal cleaning techniques and irrigation - Persistent complaints may require endoscopic surgery
Tracheostomy Care
- Explain purpose before procedure. - Inform patient and family of inability to speak while inflated cuff is used. - Tubes contain a faceplate or flange - Rest on neck between clavicles and outer cannula - During insertion, obturator is placed inside outer cannula, with rounded tip protruding from end to ease insertion - After insertion, obturator must be immediately removed to allow airflow. - Keep obturator near bedside in case of decannulation. - Some tubes have a removable inner cannula for easier cleaning.
Influenza: Symptoms
- Fever/chills - Headache - Nonproductive cough - Fatigue - Muscle aches - Sore throat - Watery, nasal drainage
Allergic Rhinitis: Treatment
- Identify and avoid triggers of allergic reactions - Drug therapy: Nasal sprays, leukotriene receptor antagonists (LTRAs), antihistamines, and decongestants to manage symptoms - Intranasal corticosteroid and cromolyn sprays (decrease inflammation locally) - Provide instructions on proper use of nasal inhalers (they can cause rebound effect from prolonged use). - Immunotherapy ("allergy injections") may be used if drugs are not tolerated or are ineffective.
Pneumonia
- Infection of lungs which leads to inflammation of the lower airways & increased mucus product - Commonly caused by staphylococcus aureus & streptococcus pneumoniae microorganisms - Commonly acquired nosocomial infection - Aspiration pneumonia - breathing bacteria into lungs
Acute Pharyngitis
- Inflammation of the pharyngeal walls - May include tonsils, palate, and uvula - Can be caused by a viral (most common), bacterial ("strep throat") swollen uvula & white spots, or fungal yeast infection (candidasis) - Usually uncomplicated but can be life-threatening is it causes airway obstruction - Assess C&S
Rhinitis
- Irritation & inflammation of the mucus membranes of the nose - Caused by environmental factors, infectious agents, change in temperature - Causes nasal discharge & congestion, perhaps itchiness & headache as well - Antihistamines, oral decongestants, intranasal corticosteroids, ophthalmic medications to treat
Managing a Nosebleed
- Keep the patient quiet. - Place the patient in a sitting position, leaning forward, or if not possible, in a reclining position with head and shoulders elevated. - Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. - Apply ice compresses to the forehead and have the patient suck on ice (Causes vasoconstriction in nose) - Apply digital pressure if bleeding continues. - Obtain medical assistance if bleeding does not stop.
Advantages of Tracheostomy
- Less risk of long-term damage to airway - Increased comfort - Patient can eat - Increased mobility because tube is more secure
Airways
- Lined w/ mucus membranes to add moisture to inhaled air - Also helps to trap foreign particles; dust, pollen, or bacteria - Cilia, small hair-like projections help to move mucus w/ foreign material upward to be coughed out
Compliance
- Measure of ease of expansion of lungs - Product of elasticity of the lungs and elastic recoil of chest wall - When compliance is decreased the lungs are more difficult to inflate - Examples include increased fluid (pulmonary edema, ARDS, pneumonia), less elasticity w/ lung tissue (pulmonary fibrosis, sarcoidosis), and restriction of lung movement (pleural effusion) - Compliance increases with damage to alveolar walls and loss of tissue elasticity like in COPD
Basic Functions of Resp. System
- Movement of air in & out of lungs - Exchange of O2 & CO2 - Helping maintain acid-base balance
Ventilation
- Moves air in (inspiration) and out (expiration) of the lungs - Air flows through nose & pasess into nasopharynx, pharynx, larynx, trachea, and bronchi
Allergic Rhinitis: Manifestations
- Nasal congestion; sneezing; watery, itchy eyes and nose; altered sense of smell; thin, watery nasal discharge - Nasal turbinates appear pale, boggy, and swollen - Chronic exposure to allergens: Headache, congestion, pressure, postnasal drip, nasal polyps - Patient may complain of cough, hoarseness, snoring, or recurrent need to clear the throat
Epistaxis
- Nosebleed - Occurs in all ages, especially in children (anterior bleeding), and older adults (posterior bleeding) - Causes trauma, foreign bodies, nasal spray abuse, drug use - Use of blood thinning agents causes pt predisposition (Aspirin, NSAID's)
Atelectasis: Treatment
- O2 Therapy - Mucolytics - Bronchodilators
Oxyhemoglobin
- Oxygen + Hemoglobin
Diffusion
- Oxygen and CO2 move through alveolar capillary membrane through this - Movement from area of higher concentration to area of lower concentration - Continues until equilibrium is reached
Types of Lung Surgeries
- Partial laryngectomy - Supraglottic laryngectomy (voice sparing, temp. trach) - Hemilaryngectomy - Total laryngectomy
Atelectasis
- Portion of lung doesnt expand completely, decreases lung capacity to exchange gases which decreases blood oxygenation - Obstruction caused by fluid, mucus plug or tumor can cause collapsed lung - Common postoperatively r/t pain pain, immobility, lack of deep breathing & anesthesia
Total Laryngectomy
- Pre-operatively cl needs to be aware what can be expected post-op - Lose use of voice - Will have permanent tracheostomy - Excessive mucus production - Dysphagia - Lose some independence
Influenza: Treatment
- Proper hand washing - Influenza vaccine - Antipyretics - Antivirals
Pulmonary Angiography
- Radioactive dye inserted into patients vein and allows an image of the circulatory system to be taken - Determines condition of blood flow to lungs
Pharyngitis: Symptoms
- Range from "scratchy throat" to severe pain - Appearance not always diagnostic; cultures or rapid strep antigen test needed
Thoracentesis
- Removal of fluid from pleural sac to drain fluid or identify contents of fluid - Pt lays on unaffected side, local anesthetic is used and needle is inserted to drain fluid into syringe
Total Laryngectomy: Complications
- Respiratory distress, hemorrhage - Infection, wound breakdown
Chemoreceptors
- Respond to changes in fluids around them -Respond when changes in CO2 & O2 occur - Low O2 = Breathe more
Mechanical Receptors
- Responds to abnormal changes in lungs - Stimulated by irritants like smoke, dust, or pollen - Muscle stretching occurs
Sleep Apnea
- Risk factors include obesity & cigarette smoking - Can tax heart & lungs and causes high B/P - Treatment includes medications & CPAP machine
Barrel Chest
- Rounded/Bulging chest - Commonly found in pt w/ Osteoarthritis which can stiffen the joints where the ribs attach to the spine - Also found in pt w/ emphysema
Deviated Septum
- Septum displaces to one side and can partially occlude the nostril
Vesicular sounds
- Soft, blowing, or rustling sounds normally heard throughout most of the lung fields - Normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.
Wheezes (2 Kinds)
- Sonorous: sounds like snoring - Silibant: high pitched
Broncho-Vesicular sounds
- Sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. - Softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Sputum Culture
- Sputum collected from pt in sterile container and sent to lab to assess for bacteria involved - Takes 72 hours to complete testing process
Tracheostomy
- Stoma that results from tracheotomy
Tracheostomy Care Continued
- Suctioning the airway to remove secretions - Cleaning around stoma - Changing ties - Providing inner cannula care - Tube with inflated cuff is used for risk of aspiration or in mechanical ventilation. - Inflate cuff with minimum volume required to create an airway seal. - When patient can protect against aspiration and does not require mechanical ventilation, a cuffless tube is used.
Viral Rhinitis: Treatment
- Supportive therapy such as rest, fluids, proper diet, antipyretics, and analgesics
Tracheotomy
- Surgical incision into the trachea to establish an airway
Airway Obstruction: Symptoms
- Symptoms: Stridor; use of accessory muscles; suprasternal and intercostal retractions; wheezing; restlessness; tachycardia; cyanosis
Pulmonary Function Test
- Test done to assess lung's ability to move air - Monitor for changes from normal functions - Use of incentive spirometer to calculate tidal volume & vital capacity
658. The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse will include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.
1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. The client is advised of the side effects of the medication and ways of minimizing them to ensure compliance. The client is reassured that, after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. The client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. The client is instructed about thorough handwashing and to cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and, when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.
671. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia
1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well.
673. A nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection
1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary.
670. A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing
1.Positive Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5mm. The client without HIV is positive with an induration larger than 10mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations
664. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome (ARDS)
1.Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side.Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi
660. Thenurseispreparingtosuctionaclientviaatracheostomytube.Thenurseshouldplantolimitthesuctioningtimetoamaximumofwhichtimeperiod? 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds
3. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10seconds
655. An emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of a pneumothorax? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
2. Diminished breath sounds Rationale: The client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
656. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note on an assessment of this client? Select all that apply. 1. Hypocapnia 2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration
2. Dyspnea on exertion 3. Presence of a productive cough Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pilmonary function tests will demonstrate decreased vital capacity
668. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear
2.Particulate respirator, gown, and gloves Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath
666.The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1.Palpation and clubbing 2.Percussion and vibration 3.Hyperoxygenation and suctioning 4.Administer a bronchodilator and monitor peak flow
2.Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the clients so that gravity can help mucus moving from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions
674. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar
2.Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
678. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen. 2. Check the client's vital signs. 3. Ventilate the client manually. 4. Start cardiopulmonary resuscitation (CPR).
3. Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.
659. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client,should be reported immediately to the healthcare provider? 1.Dry cough 2.Hematuria 3.Bronchospasm 4.Blood-streaked sputum
3.Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure
669. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot ,flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken
3.Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis
663. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation
3.Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest
677. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1.Chest x-ray 2.Bronchoscopy 3.Sputum culture 4.Tuberculin skin test
3.Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy
661. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate? 1.Continue to suction. 2.Notify the healthcare provider immediately. 3.Stop the procedure and reoxygenate the client. 4.Ensure that the suction is limited to 15 seconds
3.Stop the procedure and reoxygenate the client. Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
Hemoptysis
Coughing up blood
667. A nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for 1½ weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 2 months." 2. "I can't shop at the mall for the next 6 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."
4. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds, until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.
657. A nurse instructs a client about pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.
4. Promote carbon dioxide elimination. Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation.
672. The nurse is giving discharge instructions to the client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath
4. Shortness of breath Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.
675. A nurse is instructioning a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed, leaning on an overbed table
4. Sitting on the side of the bed, leaning on an overbed table Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall.
676.The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis? 1.Dyspnea 2.Chest pain 3.A bloody, productive cough 4.A cough with the expectoration of mucoid sputum
4.A cough with the expectoration of mucoid sputum Rationale: One of the first pulmonary manifestations of tuberculosis is a slight cough with the expectoration of mucoid sputum. Options 1, 2, and 3 are late manifestations and signify cavitation and extensive lung involvement
665. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercosta lretractions 4.Increased respiratory rate
4.Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles
662. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1.Slow deep respirations 2.Rapid deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration
4.Pain, especially with inspiration Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest
Cyanosis
Blue discoloration r/t poor circulation or inadequate oxygenation of blood
Dyspnea
Difficulty breathing
Hypoxemia
Low O2 concentration in arterial blood
Hypoxia
Low O2 supply
Orthopnea
Shortness of breath when laying down
