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Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "If the test area turns red that means I have tuberculosis." "I will avoid contact with my family until I am done with the test." "Because I had a previous reaction to the test, this time I need to get a chest X-ray." "I will come back in 1 week to have the test read."
"Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? "You must consume a diet rich in protein, such as chicken, fish, and beans." "You must consume a diet low in fat by limiting dairy products and concentrated sweets." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables."
"You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? 0 to 4 mm 7 to 8 mm 5 to 6 mm 9 mm
0 to 4 mm Explanation: The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 2 to 4 months 1 to 3 weeks 6 to 12 months 3 to 5 days
6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client with a nasogastric tube A client who ambulates in the hallway every 4 hours A client who is receiving acetaminophen (Tylenol) for pain
A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? A disease process is present. The ET tube must be pulled back. The X-ray is inconclusive. The ET tube must be advanced.
A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis
Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.
A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare to start an I.V. line. Prepare a chest tube insertion tray.
Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse Sets a schedule to suction the tracheostomy every hour Encourages the client to cough every 30 minutes and prn Assesses the client's tracheostomy and lung sounds every 15 minutes Decreases the amount of humidity set to flow through the tracheostomy tube
Assesses the client's tracheostomy and lung sounds every 15 minutes Explanation: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? Blood-tinged sputum Bradypnea Productive cough Respiratory alkalosis
Blood-tinged sputum Explanation: The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.
A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client? Beta blockers Angiotensin receptor blockers Calcium channel blockers Angiotensin converting enzyme inhibitor
Calcium channel blockers Explanation: Clients with a positive vasoreactivity test may be prescribed calcium channel blockers. Calcium channel blockers have a significant advantage over other medications taken to treat PH in that they may be taken orally and are generally less costly; however, because calcium channel blockers are indicated in only a small percentage of clients, other treatment options, including prostanoids, are often necessary (Hopkins & Rubin, 2016).
You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? Direct lung damage Drug ingestion Chemical irritation Aspiration
Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? Classes at community centers to teach about smoking cessation strategies Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes Legislation that requires homes and apartments be checked for asbestos leakage
Classes at community centers to teach about smoking cessation strategies Explanation: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Continuous positive airway pressure (CPAP) Surgery to remove the tonsils and adenoids Bi-level positive airway pressure (BiPAP) Medications to assist the patient with sleep at night
Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Sibilant wheezes Pleural friction rub Low-pitched rhonchi during expiration Crackles in the lung bases
Crackles in the lung bases Explanation: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake. Offer nutritious snacks 2 times a day.
Encourage increased fluid intake. Explanation: The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.
A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention? Encourage the client to cough Perform chest physiotherapy Perform postural drainage Perform nasotracheal suctioning
Encourage the client to cough Explanation: If the client is retaining secretions, the nurse should first encourage the client to cough before performing more invasive interventions.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Use of a cooling blanket Incentive spirometry Endotracheal suctioning Encouragement of coughing
Endotracheal suctioning Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increase in women smokers Increased incidence among the elderly Increased exposure to industrial pollutants Few early symptoms
Few early symptoms Explanation: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.
The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? How to splint the incision when coughing How to take prophylactic antibiotics correctly How to manage the need for fluid restriction How to milk the chest tubing
How to splint the incision when coughing Explanation: Prior to thoracotomy, the nurse educates the client about how to splint the incision with the hands, a pillow, or a folded towel. The client is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypotension, hyperoxemia, and hypercapnia Hypercapnia, hypoventilation, and hypoxemia
Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote more efficient and controlled ventilation and to decrease the work of breathing Promote the client's ability to take in oxygen Promote the strengthening of the client's diaphragm Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Increased restlessness Decreased level of consciousness (LOC) Decreased heart rate Increased blood pressure
Increased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Administer bronchodilators and mucolytic agents following the sequence. Perform this measure with the client once a day. Use aerosol sprays to deodorize the client's environment after postural drainage. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Explanation: Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Synchronized intermittent mandatory ventilation (SIMV) Intermittent mandatory ventilation (IMV) Assist control Pressure support
Intermittent mandatory ventilation (IMV) Explanation: IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? Inflate the cuff to the highest possible pressure in order to prevent aspiration. Deflate the cuff overnight to prevent tracheal tissue trauma. Monitor the pressure in the cuff at least every 8 hours Keep the tracheostomy tube plugged at all times.
Monitor the pressure in the cuff at least every 8 hours Explanation: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the client from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? Hypertension Cyanosis Wheezing Paradoxical chest movement
Paradoxical chest movement Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. Upon expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the client's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Bicarbonate (HCO3-) Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2)
Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? Placing the client in respiratory isolation Assessing the client's temperature every 8 hours Monitoring the client's fluid intake and output Wearing gloves during all client contact
Placing the client in respiratory isolation Explanation: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Myocardial infarction (MI) Pulmonary embolism Heart failure Pneumothorax
Pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? Removal from oxygen, ventilator, and then tube Removal from the ventilator, tube, and then oxygen Removal of the tube, oxygen, and then ventilator Removal from oxygen, tube, and then ventilator
Removal from the ventilator, tube, and then oxygen Explanation: The process of withdrawing the client from dependence on the ventilator takes place in three stages: the client is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if the wall suction unit has malfunctioned. See if the chest tube is clogged. See if a kink has developed in the tubing. See if there are leaks in the system.
See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.
The most diagnostic clinical symptom of pleurisy is: Dyspnea and coughing. Stabbing pain during respiratory movements. Dullness or flatness on percussion over areas of collected fluid. Fever and chills.
Stabbing pain during respiratory movements. Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To monitor bleeding around the lungs To assist with mechanical ventilation To drain copious sputum secretions To remove air from the pleural space
To remove air from the pleural space Explanation: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Keeping the head of the bed at 15 degrees or less Using strict hand hygiene Turning the client every 4 hours to prevent fatigue Providing oral hygiene daily
Turn onto the affected side. Explanation: Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
Using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Influenza vaccine will prevent typical pneumonias." "Viruses like influenza are the most common cause of pneumonia." "Getting the flu can complicate pneumonia." "Influenza is the major cause of death in the United States."
Viruses like influenza are the most common cause of pneumonia." Explanation: Influenza type A is a common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin D Vitamin B6 Vitamin E Vitamin C
Vitamin B6 Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Time cycled Volume cycled Pressure cycled Negative pressure
Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
The nurse is planning for the care of a client with acute tracheobronchitis. What nursing interventions should be included in the plan of care? Select all that apply. Giving 3 L fluid per day Administering a narcotic analgesic for pain Increasing fluid intake to remove secretions Encouraging the client to rest Using cool-vapor therapy to relieve laryngeal and tracheal irritation
increasing fluid intake to remove secretions encouraging patient to remain in bed using cool-vapor therapy to relieve laryngeal & tracheal irritation Explanation: In most cases, treatment of tracheobronchitis is largely symptomatic. Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. A primary nursing function is to encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Fatigue is a consequence of tracheobronchitis; therefore, the nurse cautions the client against overexertion, which can induce a relapse or exacerbation of the infection. The client is advised to rest.
A client reports dyspnea, fatigue, and having had a persistent productive cough for the last few months, which the client attributes to a bout with the flu. The nurse suspects that this client may have: pleurisy. pleural effusion. lung cancer. lung abscess.
lung cancer. Explanation: Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. The sputum is examined for malignant cells. Chest x-rays may or may not show a tumor. With pleurisy, the client's respirations become shallow secondary to excruciating pain. The client may have a dry cough, fatigue easily, and experience dyspnea. Fever, pain, and dyspnea are the most common symptoms of pleural effusion. Signs and symptoms of lung abscess include chills, fever, weight loss, chest pain, and a productive cough.
Arterial blood gas analysis would reveal which value related to acute respiratory failure? pH 7.35 PaCO2 32 mm Hg PaO2 80 mm Hg pH 7.28
pH 7.28 Explanation: Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. hemothorax. consolidation. pneumothorax.
pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process. Reference:
