ATI Targeted MS Respiratory

A nurse in ED is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen B. Increase the rate of IV fluids C. Administer pain medication D. Initiate cardiac monitoring

A .Apply supplemental O2 using airway, breathing, circulation -greatest risk to client is severe hypoxemia. Therefore it is supplemental O2 Others aren't priority

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A. A client who has epistaxis B. A client who has amyotrophic lateral sclerosis C. A client who has pneumonia D. A client who has emphysema

A. A client who has epistaxis Should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because the intervention might cause an increase in bleeding amyotrophic lateral sclerosis, pneumonia, and emphysema can receive NGT suction

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify provider if there is a fluctuation of drainage in the tubing with inspection" B. " I will notify the provider if there is a continuous bubbling in the water seal chamber" C. "I will notify the provider if there is drainage of 60mL in the first hour after surgery" D. "I will notify the provider if there are several small, dark-red blood clots in the tubing"

B. " I will notify the provider if there is a continuous bubbling in the water seal chamber" Continuous bubbling suggests air leak and requires notification of the providers. The nurse should check the system for external correctable leaks while waiting for instructions from provider -fluctuation of drainage in tubing with inspiration is expected finding, need cont. monitoring but not notifying - Drainage of 60mL in the first hour after surgery is expected finding - small, dark-red blood clots is expected finding

A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased O2Sat C. Urinary retention D. Increased pain level

B. Decreased O2Sat When using airway, breathing, circulation approach, the nurse should identify decreased o2sat as the priority finding to address and report to the provider- postop of total laryngeal is at higher risk for hypoxia because airway obstruction - others are necessary but not priority

A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow back and over the chest to support the arm B. High-Fowler's position with the arms supported on the overbed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the HOB to 15 degree

B. High-Fowler's position with the arms supported on the overbed table Should place in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillow for comfort on the overbed table. - lateral position can be a good position for sleeping but not promote max. Chest expansion - supine allows diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise expansion

A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears in an adverse effect of this medication" B. "Have your skin test repeated in 4 months to show a positive result" C. "Expect your urine and other secretions to be orange while taking this medication" D. "Remember to take this medication with a sip of water just before your first bite of each meal"

C. "Expect your urine and other secretions to be orange while taking this medication" Rifampin will turn urine and other secretions orange. It is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise - Tinnitus isn't AE but GI disturbance is - purified protein deviation skin test results will continue to show positive, even after disease is no longer active - should instruct client to take rifampin 1 hr before or 2 hr after meal

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "I will use clean technique when suctioning a client's ETT" B. "I will use a rotating motion when removing the suction catheter" C. "I will suction the oropharyngeal cavity prior to suctioning the ETT" D. "I will suction a client's ETT every 2 hours"

C. "I will suction the oropharyngeal cavity prior to suctioning the ETT" Should rotate catheter during withdrawal to remove secretion from the side of the airway -Should suction ETT prior to suctioning the nonsterile oropharyngeal cavity to prevent cross contamination - should use sterile technique to avoid introduction of pathogen - Should suction ETT only when needed

A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best methods for the nurse to use to determine the effectiveness of the current treatment regimen? A. Blood pressure B. Capillary refill C. Arterial blood gases D. Heart rate

C. ABG when using airway, breathing, circulation approach- priority on evaluating ABG to determine serum O2Sat and acid-base balance others aren't priority

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma B. I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage C. I should remove the old twill ties after the new ties are in place D. I should apply suction while inserting catheter into my tracheostomy tube.

C. I should remove the old twill ties after the new ties are in place As a safety measure, the nurse should teach the client to wait until the new tie are in place to remove the old ties. This practice can prevent accidental decannulation - should use gauze squares moistened in 0.9% NS to cleanse around the stoma or half-strength hydrogen peroxide can be used on the skin to dean crusty area. Using a cotton-tipped applicator places the client at risk for aspiration of cotton fibers. Also, client should be careful not to get hydrogen peroxide into the tracheal stoma. - cutting 4-inch square dressing places the client at risk for aspiration of gauze fibers. Should apply a commercially-prepared split gauze tracheostomy dressing under the flange of the tracheostomy tube. - Client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis

C. Tachycardia Should monitor tachycardia which is common adverse effect of this medication especially if albuterol on regular basis - should monitor hypokalemia, decreased in dyspnea (therapeutic effects) for albuterol ,and candidiasis for inhaled glucocorticoid, not albuterol

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority? A. Provide a quiet environment B. Encourage use of incentive spirometry every 1 to 2 hr C. Obtain a blood sample for electrolyte study D. Administer heparin via continuous IV infusion

D. Administer heparin via continuous IV infusion Airway, breathing, circulation approach to client care- should place priority on stabilizing circulations to the lungs by administering heparin to prevent further clot formation - others aren't priority

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prdnisone C.Fluticasone/salmeterol D. Albuterol

D. Albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack. Cromolyn is for maintenance therapy of asthma Prednisone is for after acute attack to promote anti-inflammatory effects Fluticasone/salmeterol is for maintenance therapy of asthma

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? A. I will monitor my heart rate every day while taking this medication B. I will make sure I have this medication with me all the time C. I will need to carefully rinse my mouth after I take this medication D. I will take this medication every night even if I don't have symptoms

D. I will take this medication every night even if I don't have symptoms Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening - Client who take SABA should monitor heart rate because tachycardia is AE of these medications - who take SABA should have their medication all the time with them - to relieve bronchoconstriction during asthma attack - who take inhaled glucocorticoids should rinse their mouths and gargle after use because oral candidiasis is AE

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24mEq/L D. Intercostal retractions

D. Intercostal retractions should report intercostal retractions to the provider because the finding indicates increasing respiratory compromise in client who has ARDS - decreased bowel sound is expected finding - O2Sat, and CO2 are WNL

A nurse is an emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? A. Arterial pH.7.50 B. PaCo2 25 mmHg C. SaO2 92% D. PaO2 58 mmHg

D. PaO2 58 mmHG should expect the client who have lower partial pressures of oxygen - should expect pH level to decrease because respiratory failure can cause respiratory acidosis -should expect client's CO2 level to rise with acute respiratory failure - should expect the client to have a decrease in O2 saturation

A nurse is assessing a patient who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Decreased fremitus B. SaO2 95% on RA C. T 38.8C (101.8F) D. Bradypnea

T 38.8C Elevated T, increased fremitus, lower than 95% SaO2, and tachypnea are expecting finding for a client who has bacterial pneumonia

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A. A client who is 48hr postoperative following a total arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. DVT are most likely to occur 48-72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stocking and by administering anticoagulant medications - open surgical appendectomy- at low risk of PE. Greatest risk is peritonitis -open reduction external fixation- low risk- greatest risk to the client is neurovascular compromise - laparoscopic cholecystectomy is at low risk for PE- some clients develop from CO retention in the abdomen following surgery.

A nurse is developing a plan of care for a client who has active tuberculosis. Which of the following isolation precautions should the nurse include in the plan? A. Airborne B. neutropenic C. Contact D. Droplet

A. Airborne because TB is respiratory infection that is spread through the air- negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Should not enter without N95 - initiate protective environment precautions for clients who need protection from outside infections, such as client who are receiving bone marrow transplants - should initiate contact precautions for infection that are transmitted by direct contact- scabies, MRSA - droplet precautions for clients who have infection that transmitted by large droplets in air and by being within 3ft of client- influenza- should wear surgical mask within 3 ft

A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema

A. Blood-tinged sputum blood tinged-sputum is secondary to bleeding from the tumor - should expect increased tactile fremitus, not decrease because tumor tissue or fluid replacing airplace - should expect dullness rather than resonance- because of presence of masses in the lungs - should expect cyanosis of the lips and fingertips but not peripheral edema is not expected findings

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should identify that which of the following assessments is the priority? A. Presence of gag reflex B. Pain level rating using a 0 to 10 scale C. Hydration status D. Appearance of the IV insertion site

A. Presence of gag reflex Greatest risk to the client is aspiration due to a depressed gag reflex. At risk for increased pain, hydration (due to NPO for 4-8hrs which increase risk for dehydration), and for phlebitis (should assess redness, warmth, and drainage at IV insertion site) but not priority

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should nurse take? (Select all that apply) A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution C. Instruct the client to take deep breath during the procedure D. Position the client laterally on the affected side before the procedure E. APply pressure to the site after the procedure

A. Wear goggles and a mask during the procedure B. Cleanse the procedure area with an antiseptic solution E. APply pressure to the site after the procedure Nurse and provider both need to wear goggle and mask to reduce the risk for exposure to pleural fluid Use of antiseptic solution decreases the risk for infection which is increased due to invasive nature of procedure Application of pressure decreases the risk for bleeding at the procedure site - should instruct client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung - should position client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

B. Elevated temperature should report an elevated T to the provider because it can indicate a possible respiratory infection. Client who have emphysema are at risk for the development of pneumonia and other respiratory infections - rhonchi on inspiration, barrel-shaped chest, diminished breath sounds are expected findings

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

B. Nonrebreather mask Should use nonrebreather mask for a client who is in respiratory distress to provide highest oxygen level. A nonrebreather mask i s made up of a reservoir bad from which the client obtains the O2, a one-way valve to prevent exhaled air form entering the reservior bad, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2 -O2 flow rate via nasal cannula is 1-6L/min and provides O2 at a concentration of 24% to 44%. It does not provide the highest level of O2 for client who is in respiratory distress - simple face mask delivers O2 conc. Between 40-60% and has open exhalation ports that allow RA in and exhaled air out. It doesn't provide highest level of O2 for a client who is in respiratory distress - The partial rebreather mask delivers O2 conc. 60-75%. The exhalation ports are open, which will allow RA in and exhaled air out.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pused-lip breathing with exertion

B. Productive cough with green sputum When using urgent vs. nonurgent approach to client care, priority finding is a productive cough with green sputum- it indicate infection - increased diameter is nonurgent because expected findings - clubbing is nonurgent because COPD is chronic low arterial oxygen level. - Pursed-lip is nonurgent because it is expected findings with COPD

A nurse is caring a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A.. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

C. Artificial airway cuff leak Cuff leak interferes who oxygenation and causes the low-pressure alarm to sound - excess secretion, kink, biting will cause high-pressure alarm

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal set C. Container of sterile water D. Nonadherent pads

C. Container of sterile water Should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax -other choices don't require at bedside

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3 C (99.1F)

C. Persistent cough When using airway, breathing, circulation approach to client care, nurse should determine the priority finding is a persistent cough because this can indicate tension pneumothroax, which is a medical emergency - pallor indicates blood loss, insertion site pain can result in shallow respiration, and temperature can indicate infection but they aren't priority

A nurse is creating a plan for care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals B. Have the client sit up in a chair for 2-hr periods three times per day C. Provide a diet that is high in calories and protein D. Combine activities to allow for longer rest periods between activities

C. Provide a diet that is high in calories and protein The nurse should provide diet is high in calories and protein and low in carbohydrates - should schedule respiratory treatment before meals - should provide short period of activity frequently throughout the day - should schedule activities that are short in duration with adequate rest periods between to prevent fatigue

A nurse working in an ED is caring for a client following an acute chest trauma. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

D. Tracheal deviation to the unaffected side Deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing tension pneumothorax. - results from free air filling the chest cavity causing lung to collapse and forcing the trachea to deviate to the unaffected side