Evolve Resp
After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?
Turning and positioning
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. The nurse should suggest that the client:
Use a humidifier in the bedroom
What must the nurse do when performing tracheostomy care?
Use sterile gloves when touching the inner cannula
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished?
Assess the person's breathing
A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include?
Helping the client set a date to stop smoking
A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess this client?
Hoarseness
The nurse evaluates that the preoperative teaching regarding a bronchoscopy was understood when the client states, "I recognize I cannot eat or drink for several hours after the procedure to prevent:
"Aspiration of food."
An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response?
"Avoid putting your hands near your nose and mouth."
After a thoracentesis is performed for pleural effusion, a client returns to the health care provider's office for a follow-up visit. Which client statement leads the nurse to suspect a recurrence of the pleural effusion?
"I get a sharp pain when I take a deep breath."
A nurse provides smoking cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client states:
"I'll cut back to a half pack a day."
A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further instruction?
"I'm upset to know that the tumor may metastasize to my bones."
A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?
"Tell me more about the conversation you had with your health care provider."
A client complains of left-sided chest pain after the client finished playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify:
Absence of breath sounds on auscultation
What nursing action will limit hypoxia when suctioning a client's airway?
Apply suction only after catheter is inserted
A client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is in?
Bargaining
A nurse teaches a client how to perform diaphragmatic breathing. The nurse advises the client to:
Expand the abdomen on inhalation
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. The priority nursing assessments are:
Quality of respirations and presence of pulses
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube?
Restores negative pressure in the pleural space
To evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax, the nurse assesses for:
Return of breath sounds
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider?
Severe shortness of breath
A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?
Yellow sclera
What response provides evidence that a client with chronic obstructive pulmonary disease (COPD) understands the nurse's instructions about an appropriate breathing technique?
Holds each breath for a second at the end of inspiration
A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to:
Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?
Shortness of breath with crackles
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?
Give prescribed drugs to promote bronchiolar dilation
A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective?
Has a productive cough
A nurse is caring for a client with a pneumothorax that has a chest tube attached to a closed chest drainage system. If the chest tube and closed-chest drainage system are effective, the type of pressure that will be reestablished is:
Negative pressure in the pleural space
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should:
Administer oxygen at a low concentration to maintain respiratory drive
The nurse is caring for a 75-year-old client that had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. The nurse should:
Administer the prescribed oxygen
A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent?
An inaccurate interpretation
What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?
Apply a precut dressing around the insertion site with the flaps pointing upward
A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. The preceptor informs the orientee that the instructions given to the client were:
Appropriate; oral intake after the procedure may result in aspiration
After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should
Check the system for air leaks
A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination medication, Rifamate, composed of rifampin (Rifadin) and isoniazid (INH). The nurse evaluates that the teaching regarding the drug is effective when the client says, "The most important thing I must do is:
Continue taking the medicine even after I feel better
The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include:
Coughing and deep breathing every hour
A client's respiratory status may be affected after abdominal surgery. The nurse documents the behavioral objective for this client. What statement is a behavioral objective?
Demonstrates the technique of coughing and deep breathing
A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is:
Difficulty in expelling the air trapped in the alveoli
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?
Diminished breath sounds on auscultation
The nurse assists with a client's yearly physical examination. After the examination is completed, the client is diagnosed with tuberculosis. Which action best reflects appropriate epidemiological follow-up?
Encouraging close family members, friends, and coworkers of the client to have a skin test
A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, the most important nursing intervention is to:
Ensure nothing by mouth (NPO) until the gag reflex returns
A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is:
Expected, but needs to be addressed
A nurse is caring for a client who experienced a crushing chest injury. A chest tube was inserted. Which observation indicates a desired response to this treatment?
Increased breath sounds
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain?
Presence of a cough and pulmonary secretions
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, the nurse should:
Provide a means for the client to write
A client newly diagnosed with tuberculosis has a productive cough. The most appropriate nursing intervention is to teach the client to:
Use disposable tissues
