Respiratory System
Which pulmonary risk may be increased in a postoperative client due to anesthesia?
Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. This condition is caused by the effects of anesthesia. Rhonchi are continuous rumbling or snoring sounds caused by the obstruction of the larger airways. Fremitus is the vibration of the chest wall during vocalization. Dyspnea is shortness of breath; this condition is an after effect of atelectasis.
A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. When caring for this client, what should the nurse do?
Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client?
Improving ventilation provides comfort, maintains existing lung function, and prevents further lung damage. Maintaining, not limiting, hydration thins secretions so that ventilation is improved. Oxygen administration should be maintained at no higher than 2 L per minute; this provides oxygen while preventing the development of CO2 narcosis. Bicarbonate usually is not given because the client probably is in compensated respiratory acidosis.
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record?
Resonance is a low-pitched sound heard over the lungs during percussion in healthy individuals. Breathing sounds may be considered dull if sounds are of medium-intensity pitch and duration and are heard over areas of mixed, solid, and lung tissue. Soft high-pitched sounds of short duration heard over very dense tissue where air is not present is described as a flat sound. Sounds with drum-like, loud, or empty quality heard over a gas-filled stomach or intestines are described as tympany.
Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder?
The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.
Which assessment finding is considered the earliest sign of decreased tissue oxygenation?
Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.
After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first?
Vital signs should be done after oxygen administration. Obtaining vital signs will delay an intervention that may help reduce the client's distress. The client probably has a fat embolus; oxygen reduces the surface tension of fat globules, reducing hypoxia. Interventions should be initiated to help the client before taking the time to notify the healthcare provider. Placing the client in the high-Fowler position will cause hip flexion, putting stress on the fractured femur; the low or semi-Fowler positions are preferred.
After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion?
Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is an adventitious breath sound that may indicate bronchospasm. Rhonchi are associated with obstruction by a foreign body. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.
pneumothroax
air in the pleural cavity
A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take?
The dressing should be inspected to determine the presence of hemorrhage; vital signs also should be obtained. Increasing the oxygen flow rate is contraindicated because it may precipitate CO2 narcosis in a client with emphysema. Notifying the healthcare provider should be done after the nurse performs an appropriate assessment. Placing the client in the supine position is contraindicated because it may compromise the client's respiratory status.
A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify?
Accessory muscles are used during respiration because of the increased rigidity of the chest. Sudden pleuritic chest pain is associated with pulmonary embolism, not emphysema. Respiratory acidosis, not alkalosis, is associated with emphysema because of carbon dioxide retention. Clients with respiratory muscle fatigue breathe with rapid, shallow respirations.
A nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions?
Because the client has an endotracheal tube in place, secretions can be loosened by administration of humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs.
The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first?
Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).
Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action?
Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be done eventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.
A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason?
Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped.
A client is admitted to the emergency department with multiple injuries, including fractured ribs. Which assessment is priority?
Fractured ribs cause extreme pain, especially on inhalation; this induces shallow breathing, which results in carbon dioxide retention, leading to respiratory acidosis. Although decreased respiratory functioning can result in an infection, respiratory acidosis is the immediate concern. Blood in vomitus (hematemesis) is unrelated to fractured ribs; hemoptysis will be more important than hematemesis. Pulmonary edema is unrelated to fractured ribs; it is associated with heart failure or fluid overload.
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs?
Fractured ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung, causing diminished breath sounds. This is a complication of fractured ribs. Reports of pain when taking deep breaths is an expected response to tissue trauma caused by a fractured rib. Observing the client splinting the fracture site is an expected response to tissue trauma caused by a fractured rib. Bowel sounds auscultated in the lower chest suggest rupture of the diaphragm, not fractured ribs.
A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have?
Fractures of the nose often result from injuries received during falls, sports activities, car crashes, or physical assaults. Nose fractures may lead to difficulty in breathing. Crepitus is crackling of the skin on palpitation. Sinusitis is an inflammation of the tissues lining the sinuses. In an upper respiratory tract infection, a stuffy nose and itching results in difficulty breathing. However, pain may not be present.
A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings?
Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit. There is a loss of extracellular fluid in an acute infection with a fever; however, in a chronic condition, this fluid is replenished and the hematocrit usually is unaffected. Hypercapnia is an increase in PCO2 in extracellular fluid; this does not have a direct effect on the hemoglobin and hematocrit levels.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care?
Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator; subcutaneous emphysema can also occur with a chest tube.
A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level?
Oxygen via nasal cannula [1] [2] is the most comfortable and least intrusive, because the cannula extends minimally into the nose. Use of the catheter is intrusive and may increase anxiety. A Venturi mask and a rebreather mask are oppressive, and clients complain of feeling "suffocated" when they are used.
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?
The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?
When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.
A client is informed that he has developed a healthcare-associated upper respiratory tract infection and asks the nurse what this means. How should the nurse reply?
A healthcare-associated infection (formerly called nosocomial infection) is contracted during the course of receiving treatment. Although developing an infection that requires antibiotics may occur, this response does not explain a healthcare-associated infection. The need for precautions relates to the type of infection, not to the situation in which it was acquired. A preexisting infection is unrelated to a healthcare-associated infection.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client?
Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.
The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds?
Breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection; rhonchi signify airway obstruction, not emphysema. Expiratory wheezing and coughing are associated with asthma or bronchitis.
A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply.
Client teaching regarding the manifestations of pneumothorax, partial or complete collapse of the lung, which may occur in the 24 hours after thoracentesis, is important. Manifestations that require immediate contact with the nearest emergency department are cyanosis and a feeling of air hunger. Other findings that must be reported include rapid heart rate (not decreased), a new-onset nagging cough (rather than the disappearance of such a cough), and rapid and shallow respirations (not the cessation of such respirations).
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?
Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
A 65-year old client is found to have dilatation of the bronchioles and alveolar ducts. Which suggestions of the nurse would help the client overcome this situation? Select all that apply.
Dilatation of the bronchioles and alveolar ducts is a respiratory system change related to aging. Using incentive spirometry may help clients improve functioning of the lungs. This action may help the client take breaths more easily and more comfortably. Performing vigorous pulmonary hygiene activities, such as clearing the mucus or other secretions from the airways, may help an older adult prevent respiratory infections or complications. The upright position may help in minimizing the mismatching of ventilation perfusion. Clients should take in adequate amounts of calcium daily to overcome decreased chest mobility due to osteoporosis. Face-to-face conversations are required for clients with muscle atrophy and clients whose vocal cords may have become slack.
A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client?
Loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis). Tissue necrosis results from localized tissue anoxia and will not cause the systemic response of respiratory acidosis. An increased respiratory rate may lead to respiratory alkalosis. Normal oxygen saturation of hemoglobin is 95% to 100%, so this is not a sign of acidosis.
Which chest examination findings can be observed in a client with pneumonia?
Palpation in clients with pneumonia reveals increased fremitus over the affected area. Clients with pneumonia may have bronchial sounds initially and crackles, rhonchi, egophony later. Clients with atelectasis, however, may have absent sounds on auscultation. Hyperresonance on percussion may be observed in clients with asthma exacerbation or chronic obstructive pulmonary disease. Percussion in clients with pneumonia, however, may reveal dull sounds over the affected areas. Prolonged expiration on inspection is observed in clients with asthma exacerbations. However, clients with pneumonia may have tachypnea.
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent?
Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis [1] [2]. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema?
Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?
The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.
A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. Which clinical indicator should the nurse assess in the client?
The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia. Crackles come from the alveoli, part of the lower airway; the surgery involves the upper airway. There is no evidence of abdominal distention. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Cloudy drainage may indicate infection; however, this is not an immediate postoperative complication.
A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement?
The response "I'll cut back to a half pack a day" is a positive step in reducing smoking [1] [2]; it is the first step toward stopping. The response "I'll just finish the carton that I have at home" is postponing the decision to quit. The response "I find that smoking is the only way I can relax" is rationalizing why quitting smoking is too difficult. The response "I should find this easy" is unrealistic because giving up smoking is difficult regardless of whether the client smokes when alcoholic beverages are consumed.
A client who is negative for human immunodeficiency virus (HIV) but who has a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding?
The size of the induration determines the clinical significance of the reaction; an induration of 5 mm or more is considered positive in a client with HIV, indicating exposure to the tuberculosis bacillus or vaccination with bacillus Calmette-Guérin (BCG) vaccine, not the presence of active disease. The finding of an induration of 10 mm is a positive response. The size of the induration, not the amount of erythema, is used to determine the test result. Having COPD does not alter the reading; however, HIV does.
