silvestri - Respiratory

The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area?

1. Alveoli 2. Trachea **3. Pleural space 4. Main bronchi Rationale: Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?

1. Do not exceed 1 L/min. 2. Do not exceed 2 L/min. **3. Adjust the oxygen depending on SpO2. 4. Adjust the oxygen depending on respiratory rate. Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. All other options are incorrect.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

1. Serous **2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain?

**1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10." Rationale: Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply.

**1. Anosmia **2. Chronic cough **3. Purulent nasal discharge 4. Intolerance to hot weather 5. Intolerance to strong aromas Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and strong aromas are not characteristics.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

1. The client will lose consciousness. 2. The client's sodium and chloride levels will rise. 3. The client will complain of facial numbness and tingling. **4. The client's arterial blood gas results will reflect acidosis. Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 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 1 month." 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." Rationale: The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious 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 work when the results of 3 sputum cultures are negative.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?

1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort **3. Accumulation of respiratory secretions 4. Generation of extreme negative pressure by the client Rationale: The high-pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. The remaining options identify causes for triggering the low-pressure alarm.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action?

1. Aids in exhalation 2. Moves up and inward **3. Moves downward and out 4. Makes the thoracic cage smaller Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.

Which are possible causes of upper airway obstruction? Select all that apply.

1. Thin secretions **2. Laryngeal edema **3. Head and neck cancer **4. Foreign body aspiration **5. Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply.

** 1. Get plenty of rest. **2. Increase intake of liquids. **3. Take antipyretics for fever. 4. Get a flu shot immediately. **5. Eat fruits and vegetables high in vitamin C. Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement?

**1. "I will discard used tissues in a plastic bag." 2. "I need to wash my hands at least 4 times a day." 3. "I will brush my teeth and rinse my mouth once a day." 4. "I will turn my head to the side if I need to cough or sneeze." Rationale: Used tissues are discarded in a plastic bag. The client with TB should wash the hands carefully after each contact with respiratory secretions. Oral care should be done more frequently than once a day. The client should not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

A health care provider (HCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made?

**1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2. "A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3. "It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4. "It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time." Rationale: IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore, the remaining options are incorrect.

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication?

**1. A kink in the ventilator circuit 2. A leak in the endotracheal tube cuff 3. Displacement of the endotracheal tube 4. A disconnection of the ventilator tubing Rationale: A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. The remaining options would trigger the low-pressure alarm.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

**1. A shunt unit exists. 2. Anatomical dead space is present. 3. Physiological dead space is present. 4. Ventilation-perfusion matching is occurring. Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding?

**1. Absence of dyspnea 2. Increased severity of cough 3. Dull percussion notes over lung tissue 4. Decreased tactile fremitus over lung tissue Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?

**1. Contact the health care provider (HCP). 2. Document the finding in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest radiographic study to be done. Rationale: The nurse who obtains a positive test reading should call the HCP immediately. The HCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

**1. Deflate the cuff on the tube. 2. Place the inner cannula into the tube. 3. Ensure that the client is able to speak. 4. Ensure that the client is able to swallow. Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

**1. Dyspnea 2. Headache **3. Night sweats **4. A bloody, productive cough **5. A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

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 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. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

**1. Hyperoxygenate the client. 2. Set the suction pressure range at 150 mm Hg. 3. Place the catheter into the tracheostomy tube. 4. Apply suction on the catheter, and insert it into the tracheostomy tube. Rationale: The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.

The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery?

**1. Obturator 2. Oral airway 3. Epinephrine 4. Tracheostomy set with the next larger size Rationale: A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. In addition, a curved hemostat that could be used to hold the trachea open if dislodgement occurs should be kept at the bedside. An oral airway and epinephrine would not be needed.

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?

**1. Inflate the cuff on the tracheostomy tube. 2. Deflate the cuff on the tracheostomy tube. 3. Maintain the head of the bed in low Fowler's position. 4. Place the tray in a comfortable position in front of the client. Rationale: Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?

**1. It is painless and safe. 2. It causes only mild discomfort at the site. 3. It requires insertion of only a very small catheter. 4. It has an alarm to signal dangerous drops in oxygen saturation levels. Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL. How does the nurse interpret this setting?

**1. It is the amount of air delivered with each set breath. 2. It is a breath that has a greater volume than the preset tidal volume. 3. It is the number of breaths that the client will receive per minute by the ventilator. 4. It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator. Rationale: Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. The respiratory rate is the number of breaths to be delivered by the ventilator each minute. The FiO2 delivered to the client is indicated by the FiO2 indicator on the ventilator.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

**1. Just under the left clavicle 2. Midsternum, 1 inch to the left 3. Over the fifth intercostal space 4. Midsternum, 1 inch to the right Rationale: The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply.

**1. Keeping a supply of suction catheters at the bedside **2. Auscultating breath sounds to determine the need for suctioning **3. Hyperoxygenating the client before, during, and after suctioning 4. Intermittently suctioning during insertion of the suction catheter 5. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed Rationale: Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure.

The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas?

**1. Lobes 2. Alveoli 3. Trachea 4. Main bronchi Rationale: Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect.

The 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 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. Options 2, 3, and 4 are not necessary.

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.

**1. Monitor the client's temperature. **2. Use sterile technique when suctioning. **3. Use the closed-system method of suctioning. **4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle. Rationale: Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem?

**1. Pleural pain and fever 2. Decreased respiratory rate 3. Diaphoresis during the day 4. Hyperresonant breath sounds over the left thorax Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

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 Rationale: The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. 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.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

**1. Sitting up and leaning on a table **2. Standing and leaning against a wall 3. Lying supine with the feet elevated **4. Sitting up with the elbows resting on knees 5. Lying on the back in a low Fowler's position Rationale: The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action?

**1. Suction the client. 2. Evaluate the cuff for a leak. 3. Assess for a disconnection. 4. Notify the respiratory therapist. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. A cuff leak and disconnection would cause the low-pressure alarm to sound, so options 2 and 3 can be eliminated. Notifying the respiratory therapist delays necessary treatment.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.

**1. Suctioning the client as needed **2. Encouraging coughing every 2 hours 3. Placing the bed in low Fowler's position **4. Supporting the neck incision when the client coughs **5. Monitoring the respiratory status frequently as prescribed Rationale: The client's respiratory status is promoted by the use of high Fowler's position after this surgery. Low Fowler's position is avoided because it could result in increased venous pressure on the surgical site and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when coughing, to suction periodically as needed, and to monitor the respiratory status frequently as prescribed.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?

**1. Suctioning the client every hour 2. Applying suction only during withdrawal of the catheter 3. Hyperventilating the client with 100% oxygen before suctioning 4. Applying suction intermittently during withdrawal of the catheter Rationale: The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

**1. Tidaling is present. 2. There is a leak in the system. 3. The client has residual pneumothorax. 4. Suction should be added to the system. Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. Options 2, 3, and 4 are inaccurate interpretations.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.

**1. Water or a kink in the tubing **2. Biting on the endotracheal tube **3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client ceasing spontaneous breathing Rationale: Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse 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 already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to 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 already have been exposed.* *5. Cover the mouth and nose when coughing or sneezing and put used tissues in 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 needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 5 seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds

*2. 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 10 seconds.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1. A low arterial PCo2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

*2. A hyperinflated chest noted on the chest x-ray* *3. Decreased oxygen saturation with mild exercise* Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? 1. Do nothing, because this is an expected finding. 2.Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Clamp the chest tube and notify the health care provider immediately.

*2. Check for an air leak, because the bubbling should be intermittent.* Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 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: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia

*2. Flushing* Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

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 health care 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 of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

*3. Drainage system maintained below the client's chest* *4. 50 mL of drainage in the drainage collection chamber* *5. Occlusive dressing in place over the chest tube insertion site* *6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation* Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

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 appropriate? 1. Continue to suction. 2. Notify the health care 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 adverse 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.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

*4. Perform the Valsalva maneuver.* Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states 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 that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?

1. "I need to protect the stoma from water." 2. "Soaps should be avoided near the stoma." **3. "I should use diluted alcohol on the stoma to clean it." 4. "I should apply a non-oil-based ointment to the skin surrounding the stoma." Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching?

1. "I should avoid heavy lifting for at least 4 to 6 weeks." **2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider." Rationale: When a chest tube is removed, an occlusive dressing, usually consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the health care provider says it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.

The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?

1. "I should restrict my fluid intake for 2 weeks." **2. "I should perform arm exercises 2 or 3 times a day." 3. "If I experience any soreness in my chest or shoulder, I should notify the health care provider." 4. "If I experience any numbness or altered sensation around the incision, I should contact the health care provider." Rationale: The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the health care provider if these symptoms occur.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

1. "It will enter the left main bronchus if inserted too far." **2. "It will enter the right main bronchus if inserted too far." 3. "It may enter the left main bronchus if not inserted far enough." 4. "It may enter the right main bronchus if not inserted far enough." Rationale: If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

1. "Strapping is useful only if the ribs are fractured in several places at once." 2. "That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." **3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4. "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store." Rationale: Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

1. "You lack the energy to cook wholesome meals." **2. "Blocked nasal passages impair the sense of smell." 3. "Loss of appetite is triggered by the infectious organism." 4. "Infection blocks sensation in the taste buds of the tongue." Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client?

1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." **4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Rationale: Clients should be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time?

1. 1 or 2 days 2. 1 to 2 weeks 3. Almost 1 week **4. Several weeks to months Rationale: The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure?

1. 16% **2. 21% 3. 30% 4. 40% Rationale: Room air contains 21% oxygen. It is not possible to give a client 16% oxygen because that is less than room air. Options 3 and 4 specify oxygen amounts that commonly are used to supplement clients who are experiencing respiratory difficulty.

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long?

1. 6 to 12 hours 2. 12 to 24 hours 3. 24 to 28 hours **4. 48 to 72 hours Rationale: The tuberculin skin test is an accurate and reliable test that will provide information to the health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result should be done 48 to 72 hours after the injection.

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?

1. A tubing obstruction or kink 2. The accumulation of secretions **3. Disconnection of the ventilator tubing 4. Condensation of water in the ventilator tubing Rationale: The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. The remaining options identify causes for triggering the high-pressure alarm.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?

1. Administration of plasma expanders, low-flow oxygen, and suctioning 2. Administration of bronchodilators, intubation, and mechanical ventilation **3. Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4. Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask Rationale: Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. The remaining options are incorrect.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm?

1. Aids in exhalation as it contracts 2. Moves up and inward as it contracts **3. Moves downward and out as it contracts 4. Makes the thoracic cage smaller as it contracts Rationale: As the diaphragm contracts it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, the remaining options are incorrect.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

1. Air flows by gravity. **2. The respiratory muscles relax. 3. The respiratory muscles contract. 4. Air is flowing against a pressure gradient. Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness?

1. Allow the client to deal with the disease in an individual fashion. 2. Ask family members whether they wish a psychiatric consultation. 3. Encourage the client to visit with the pastoral care department's chaplain. **4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale: A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?

1. Ask a family member to stay with the client at all times. 2. Ask the health care provider for a prescription for succinylcholine. 3. Encourage the client to sleep until arterial blood gas results improve. **4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Rationale: Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?

1. Drink hot tea throughout the day. 2. Drink hot cocoa instead of coffee. 3. Restrict fluid intake to 1000 mL daily. **4. Eat foods that are highly seasoned in moderation. Rationale: Foods that are highly seasoned are irritating to the throat and should be completely avoided. The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider (HCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

1. Atelectasis and viral infection 2. Bronchoconstriction and stridor **3. Collapse of alveoli and decreased compliance 4. Decreased ciliary action and retained secretions Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

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. Intercostal retractions **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.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

1. Check for an air leak. **2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

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 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.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside?

1. Code cart **2. Intubation tray 3. Thoracentesis tray 4. Chest tube and drainage system Rationale: The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

1. Continue to monitor. 2. Document the findings. 3. Change the chest tube drainage system. **4. Perform a focused respiratory assessment. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system are not indicated at this time. Continuing to monitor delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.

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 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.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action?

1. Deflate the cuff. **2. Suction the ET tube. 3. Turn off the ventilator. 4. Obtain a code cart, and place it at the bedside. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

1. Dilate the major bronchi. 2. Increase surfactant production. **3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree. Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

1. Edema **2. Dyspnea 3. Frothy sputum 4. Diminished breath sounds Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

1. Effectiveness of medication therapy 2. The deep breaths that the client is taking 3. Decreased inflammatory reaction at the site **4. Accumulation of pleural fluid in the inflamed area Rationale: Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. The remaining options are incorrect interpretations.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug **4. Displacement of the endotracheal tube Rationale: The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.

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 prepare for the client?

1. Face tent **2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, 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.

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which co-existing condition in the client may cause an inaccurate pulse oximetry reading?

1. Fever 2. Epilepsy **3. Hypotension 4. Respiratory failure Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is giving discharge instructions to a 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 Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

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 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.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing?

1. Instruct the client to limit fluid intake. 2. Place the client in low Fowler's position. **3. Administer the prescribed bronchodilator. 4. Place a continuous pulse oximeter on the client. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube

1. It could enter the left main bronchus if inserted too far. **2. It could enter the right main bronchus if inserted too far. 3. It could enter the left main bronchus if not inserted far enough. 4. It could enter the right main bronchus if not inserted far enough. Rationale: If the endotracheal tube is inserted too far, the tube will travel past the trachea and enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. The other options are incorrect.

The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings?

1. It is at the first tracheal cartilaginous ring. **2. It is at the bifurcation of the right and left main bronchi. 3. It is at the point at which the larynx connects to the trachea. 4. It is at the area connecting the oropharynx to the laryngopharynx. Rationale: The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation. Options 1, 3, and 4 are incorrect interpretations.

The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease?

1. It is caused by a tick bite. 2. It is caused by contamination from cat feces. **3. It can be caused by the inhalation of spores from bird droppings. 4. It can be contagious by respiratory contact with an infected person. Rationale: Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. This disease cannot be transmitted from one person to another. Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

1. Muscle weakness in the arms and legs 2. A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C) **3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4. A heart rate of 80 beats/minute, decreased from 85 beats/minute Rationale: Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process?

1. Osmosis **2. Diffusion 3. Ionization 4. Active transport Rationale: Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?

1. Oxygen saturation of 89% **2. Respiratory rate of 16 breaths/minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube Rationale: Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

1. Pain with deep breathing 2. Increased chest tube drainage **3. Lung crackles in the remaining lung 4. Respiratory rate of 20 breaths/minute Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

1. Place the client in supine position. 2. Apply an ice collar around the client's neck. **3. Assist the client to a sitting position with the head tilted forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

1. Position the client in semi Fowler's position. 2. Add water to the suction chamber as it evaporates. **3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system. Rationale: It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply.

1. Pressure support is added to the oxygen system. **2. The T-piece is connected to the client's artificial airway. **3. The client is removed from the mechanical ventilator for a short period of time. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. **5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting. Rationale: The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients while on mechanical ventilation.

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose?

1. Prevents the client from getting a nosebleed 2. Gives the client added fluid via the respiratory tree **3. Humidifies the oxygen that is bypassing the client's nose 4. Prevents fluid loss from the lungs during mouth breathing Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. A client who is breathing through the mouth is not at risk for nosebleeds. The humidified oxygen may help keep mucous membranes moist, but it will not substantially alter fluid balance (options 2 and 4).

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate?

1. Reposition the client. **2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal, expected finding. Rationale: Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. The remaining options are incorrect.

A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status?

1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min **4. Respiratory rate of 22 breaths/min Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

1. Restricting fluids 2. Placing a pillow under the knees **3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period?

1. Serous 2. Grossly bloody **3. Serosanguineous 4. Serous with sputum Rationale: Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The remaining options are not expected findings.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?

1. Shut the alarm off and call for help. 2. Call the respiratory therapy department to fix the problem. 3. Call the health care provider (HCP) for further instructions. **4. Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device. Rationale: If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the alarm. It is not necessary to contact the HCP, although the respiratory therapist may be notified to assist in troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate the client.

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position?

1. Sims' 2. Supine 3. Side-lying **4. Semi Fowler's Rationale: After any procedure involving lung surgery, the nurse should position the client in semi Fowler's position. This position allows for maximal lung expansion and promotes drainage through the chest tube that may be placed during surgery. The positions identified in the remaining options will limit lung expansion.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should 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 up and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

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 Rationale: Rib fractures 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.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder?

1. The stretch receptors in the lungs are irritated. 2. The diaphragm is weak and is difficult to move. 3. This condition causes nerve endings to be especially sensitive. **4. The inflamed pleurae cannot glide against each other as they normally do. Rationale: Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. The remaining options are incorrect.

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?

1. Suction the client's airway. 2. Wipe the inner cannula off with a clean washcloth. 3. Dry the inner cannula thoroughly with sterile gauze. **4. Allow the inner cannula to dry after washing it with sterile water. Rationale: After washing and rinsing the inner cannula with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. The nurse would not suction a client without an inner cannula in place. This is a sterile procedure and therefore it is inaccurate to use a clean washcloth. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.

The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate?

1. Suction the client. 2. Increase the suction. **3. Document the findings. 4. Encourage coughing and deep breathing. Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

1. Suctioning is required frequently. 2. The client's skin and mucous membranes are light pink. **3. Aspiration of gastric contents occurs during suctioning. 4. Excessive secretions are suctioned from the tube and stoma. Rationale: Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?

1. Systemic tuberculosis 2. Pulmonary tuberculosis **3. Exposure to tuberculosis 4. No evidence of tuberculosis Rationale: A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Options 1, 2, and 4 are incorrect interpretations of the data presented in the question.

The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

1. Tape the ET tube in place, and note the centimeter marking at the lip line. 2. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. **3. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed. Rationale: The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use?

1. Telfa dressing and Neosporin ointment **2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape Rationale: On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the HCP as the tape of choice to make the dressing occlusive.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make?

1. The client has no risk of acquiring TB and needs no further workup. 2. The client is at increased risk for acquiring TB and needs immediate medication therapy. 3. The client's test result will be negative, and a sputum culture will be required for diagnosis. 4. The client's test result will be positive, and a chest x-ray study will be required for evaluation. Rationale: The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?

1. The skin color becomes cyanotic. 2. Secretions are becoming bloody. **3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 to 54 beats/minute. Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the health care provider. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that he or she cannot tolerate the procedure.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. **4. The chest tube may be obstructed. Rationale: Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

1. The ties leave no marks on the neck. 2. The tracheotomy can be pulled slightly away from the neck. **3. The nurse places 1 finger loosely between the tie and the neck. 4. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures. Rationale: The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the ties. Options 1, 2, and 4 are incorrect actions.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented?

1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. **4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losse

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

1. This is expected and will last for at least 1 year. **2. This is expected, and the client should gradually increase activity as tolerated. 3. This is an unexpected finding with TB, but it should resolve within 1 month or so. 4. This is a short-lived problem that should be gone within 1 week after beginning medication therapy. Rationale: The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 3, and 4 are incorrect information.

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

1. Inform the HCP. **2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe. Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded. Because this finding is expected, it is not necessary to notify the HCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.