Evolve: Respiratory

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"Tetrahydrocannabinol is an ingredient in marijuana that acts as an antiemetic in some people."

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 who had a total laryngectomy is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" What is the best response by the nurse?

"Perhaps I can have someone from the Laryngectomy Club come speak with you."

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 with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention?

Assess vital signs.

A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 70 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. What intervention should the nurse anticipate will be prescribed by the health care provider?

Breathing exercises

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a Po2 of 85 mm Hg, a PCO2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply.

Coughing Deep breathing Humidified oxygen

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.

Crackles Atelectasis Hypoxemia Severe dyspnea

A nurse is caring for a client in respiratory distress. The health care provider prescribes oxygen therapy with a Venturi mask to be set at 35% oxygen. Which mask should the nurse use to implement the prescription?

D

A client states that the health care provider said the tidal volume (TV) is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume?

Exhaled after there is a normal inspiration

The nurse evaluates that further teaching is necessary when a client who has had thoracic surgery performs postthoracotomy exercises by:

Extending the arm and bringing it up to touch the nose with a finger

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion?

Extension of cancerous lesions

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. The nurse's priority is to:

Immediately contact the primary healthcare provider

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, mild exercise is expected to cause respirations to:

Increase to 24 breaths per minute

A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. Which position is most appropriate for the nurse to place the client at this time?

Lateral with the head slightly elevated and flexed

A client who sustained chest trauma in an accident has bilateral chest tubes inserted. What is the nurse's primary responsibility when caring for this client?

Maintaining a closed system

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result?

Molecular diffusion

There is a fire on an inpatient unit at the hospital. List the actions the nurse should take in the order in which they should be performed.

Move clients and others away from the immediate vicinity of the fire. Initiate the fire code alarm system. Close the doors to the rooms on the unit. Evacuate clients and others to a safe area off the unit with the fire. Inform the clients' families that a fire is occurring.

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale?

Peripheral edema

A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via a nasal cannula?

Receives many visitors while sitting in a chair

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

A client with tuberculosis asks the nurse how long chemotherapy will be continued. The nurse's most accurate reply is:

Six to twelve months

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm?

The residual capacity of the lungs has been increased.

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Crackles are located in the smaller air passages.

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs?

Diminished breath sounds on the affected side

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

Hemoptysis Night sweats

The client with emphysema complains of increased shortness of breath and becomes anxious. The health care provider prescribes oxygen at 1 L/minute via nasal cannula. The nurse understands that this prescription is appropriate because:

High concentrations of oxygen eliminate the respiratory drive.

A nurse is preparing to insert a nasogastric tube. During insertion, which response indicates that the client is experiencing difficulty?

Inability to speak

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly?

Inhales deeply through the mouthpiece, relaxes, and then exhales.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. They are described best as:

Moist rumbling sounds that clear after coughing

A client who has emphysema for many years develops an enlarged liver. The nurse concludes that the enlarged liver is a result of:

Portal hypertension

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning.

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action is the first line of defense against an emerging influenza pandemic?

Reporting surveillance findings to appropriate public health officials

To make a definitive client diagnosis of tuberculosis, the nurse expects what diagnostic test to be prescribed?

Sputum tested for acid fast bacilli

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking?

Suggest that the client limit smoking to one pack of cigarettes a day

A client with an acute emphysemic episode is dyspneic and anxious. To decrease the dyspnea, the nurse's first action is to:

Teach the client to do rhythmic breathing

The nurse provides a teaching session related to the severe acute respiratory syndrome (SARS) virus to a group of nursing students. It is appropriate for the nurse to include that, according to evidence-based research, the condition that is related to the SARS virus is:

The common cold

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education?

The procedure is an endoscopic examination of lymph nodes

Following a laryngectomy a client experiences frequent coughing episodes and copious production of secretions. The nurse explains that the client's responses are related to:

The reaction of the mucous membranes to air that is dry and cool

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions?

Tidal volume

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 client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statement by the client indicates that further education is needed? Select all that apply.

"My urine may become discolored." "I will lose weight while on this medication." "The medication should be taken between meals." "When I'm feeling better, I can stop taking this medication."

The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter? Select all that apply.

"Readings in the green zone mean that my asthma is under control." "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day."

A nurse is caring for a female client who is receiving rifampin (Rifadin) for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply.

"This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." "This drug may reduce the effectiveness of the oral contraceptive I am taking." "My health care provider must be called immediately if my eyes and skin become yellow."

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner?

1 to 2 L via nasal cannula to keep SaO2 above 90%.

When helping a client with emphysema, the nurse employs several steps to teach pursed-lip breathing. Place these steps of the process in the correct sequence.

Assume a sitting position with shoulders back. Take a deep, slow inspiration of air. Purse lips as if to blow a whistle. Blow air through pursed lips for a time equal to inhalation. Have client give a return demonstration without prompting by the nurse.

The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate breath sounds.

On the first day after a right pneumonectomy, a client suddenly sits straight up in bed exhibiting respirations that are labored and accompanied by a crowing sound. The client's skin is pale, cool, and moist. What should the nurse do immediately?

Auscultate the left lung.

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C&S) are prescribed. Place these interventions in the order in which they should be implemented.

Bed rest Oxygen via nasal cannula Specimens for C&S Administration of an antibiotic

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. A commonality of the various stationary chest tube drainage systems is that the first chamber is designed to:

Collect drainage

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube?

Comparison of chest radiographs

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply.

Confusion Tachycardia

The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. The nurse considers that the main purpose of the third chamber of the underwater drainage system is to:

Control the amount of suction

A client has a hysterectomy, salpingoophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations should the nurse assess the client that indicates that the client may be experiencing a pulmonary embolus? Select all that apply.

Decreased oxygen saturation level Sudden onset of shortness of breath

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, the nurse most likely will identify:

Deep and rapid respirations

A health care provider prescribes oxygen therapy via nasal cannula at 2 L/min for an older, confused client with heart failure. Which nursing action is the priority?

Determining whether the client is agitated

Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action?

Elevate the head of the bed

What nursing action will most help a client obtain maximum benefits after postural drainage?

Encourage coughing deeply.

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?

Encourage deep breathing.

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client?

Encourage range of motion to the client's arm on the affected side.

Surgery is performed on a client with a parotid tumor. The postoperative arterial blood gas values are pH 7.32, Pco2 53 mm Hg, and HCO3 25 mEq/L. What action should the nurse take?

Encourage the client to take deep, cleansing breaths

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?

Encouraging a fluid intake of 3 L daily.

A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period?

Encouraging coughing and deep breathing

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of:

Excessive swallowing

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). The pathophysiologic changes associated with ARDS progress through expected phases. What phase is characterized by signs of pulmonary edema and atelectasis?

Exudative

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis? Select all that apply.

Fever Night sweats Blood-tinged sputum

When assessing a client's arterial blood gases the nurse identifies that the client is in compensated respiratory acidosis when the pH value is 7.34 and the:

HCO3 value is 50 mEq/L

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube?

Has a low-pressure cuff

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

The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client states, "I will need tube feedings until:

Healing of the incision is complete."

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

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 is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan?

Importance of cleanliness around the site of the stoma

A nurse is teaching a community health class about the risk factors for cancer. Which factor has the least influence in predisposing an individual to cancer of the larynx?

Inadequate dental hygiene

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, the nurse plans to:

Increase fluid intake to at least 2 L a day

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do?

Inhale completely and then blow out as hard and as fast as possible through the mouthpiece

A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. What initial action should the nurse take?

Inspect the dressing.

A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma?

Intrinsic

During a client's immediate postoperative period after a laryngectomy, a nursing priority is to:

Keep the trachea free of secretions

A client is diagnosed with tuberculosis associated with human immunodeficiency virus (HIV) infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started?

Liver function studies

A client on bed rest develops bronchitis and atelectasis of the right lower lobe. The nurse provides teaching about the treatment plan and explains that the recommended client position is:

Lying on the left side to promote drainage

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?

Mechanical ventilation may be required next.

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client?

Monitor oxygen saturation levels when eating.

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube with a high-volume, low-pressure cuff. What problem is prevented when the nurse uses a high-volume, low-pressure cuff?

Mucosal necrosis

How should the nurse position a client in the immediate postoperative period after a right pneumonectomy?

On the right side with the head elevated

A client with pulmonary tuberculosis is being treated in the home. What should the nurse teach the client to help control the spread of microorganisms?

Open the windows slightly throughout the house.

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

Orthopneic

A nurse identifies that a client's hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin?

PCO2

The nurse is caring for a client who is postoperative day 2 open of a cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions would be appropriate for this client? Select all that apply.

Perform frequent breath sounds assessment. Encourage turning, coughing, and deep breathing exercises.

A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include? Select all that apply.

Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?

Place client in a high-Fowler position

A client with terminal cancer signs a do-not-resuscitate (DNR) order upon admission to the hospital. When the client goes into respiratory arrest a week later, the client is not resuscitated. Which factor does the nurse determine is most relevant to the legal aspects of a DNR order?

Policies of the agency establish the status of DNR orders

An important nursing intervention that ensures adequate ventilatory exchange after surgery is:

Positioning the client laterally with the neck extended

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply.

Prevent the client's blanket from covering the adaptor's orifices. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

A client is receiving an intravenous infusion after a lobectomy for cancer of the lung. The nurse should monitor the client for which complication of intravenous therapy related specifically to postoperative lobectomy?

Pulmonary edema

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:

Pulmonary embolism

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do first?

Raise the head of the bed.

When assessing a client with pleural effusion, the nurse expects to identify:

Reduced or absent breath sounds at the base of the lung

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to:

Remove air from the pleural space

After a storm the rescue team is searching for injured people. A nurse on the team discovers a victim lying next to a broken natural gas line. The victim is not breathing and is bleeding heavily from a leg wound. How should the nurse proceed? Place care in the order of priority.

Remove the victim from the immediate vicinity. Start rescue breathing immediately. Apply surface pressure to the leg wound. Take the victim's vital signs. Transport the victim to the hospital immediately.

The nurse is caring for clients in the operating room. What physiologic function should the nurse consider that clients lose last during the induction of general anesthesia?

Respirations

A client is admitted to the emergency department with multiple injuries, including fractured ribs. The nurse should assess for signs of:

Respiratory acidosis

When caring for a client on mechanical ventilation, the nurse should monitor for which signs of hyperventilation?

Respiratory alkalosis

When caring for clients who receive anesthesia, the nurse observes the loss of physiological functions during the stages of anesthesia induction. The last function the client loses is:

Respiratory movement

Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly?

Rises in the tube of the water seal chamber during inspiration.

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?

Rupture of a subpleural bleb

A client, complaining of fatigue, is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent fatigue, the nurse should:

Schedule nursing activities to allow for rest

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

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is:

Sooty

What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis?

Sputum is free of acid-fast bacteria.

The nurse is providing postoperative care to a client with cancer of the lung that had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication?

Subcutaneous emphysema on the second postoperative day

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room?

Suction equipment

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client?

Suctioning the tracheostomy tube whenever necessary

Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse determines that the primary reason safety precautions should be implemented in the room is because oxygen:

Supports combustion

In the first 2 ½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is obtained from the client's drainage system. What should the nurse do? Select all that apply.

Take vital signs. Notify the health care provider.

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client?

The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula.

The nurse is caring for a client with cancer of the lung who is considering the biological therapy (e.g., monoclonal antibodies, interferon) that has been recommended in the client's treatment plan. The nurse recalls that this therapy is:

Used as an adjuvant therapy with other therapies

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. The nurse's primary concern is to maintain:

Ventilatory exchange

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right sided heart failure after discharge. The nurse instructs the client to assess for:

Weight gain

While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action?

Withhold the drug until additional prescriptions are obtained.

A client with acquired immunodeficiency syndrome (AIDS) is to receive aerosolized pentamidine (Pentam). Before administration, the nurse auscultates bilateral wheezes. The nurse should:

Withhold the medication and contact the healthcare provider to prescribe a bronchodilator.

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?

Palpate around the tube insertion sites for crepitus.

A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are: pH 7.32, Pco2 53 mm Hg,and HCO3 25 mEq. The nurse should take which action?

Ask the client to cough forcefully and take deep breaths

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in his bed clothes and part of it has broken off. What should the nurse do first?

Assess respiratory status

A health care provider's prescription for a client in ketoacidosis is 500 units Humulin R insulin in 500 mL lactated Ringers intravenously (IV), and administer 60 units of insulin in the next 30 minutes. At how many milliliters per hour should the nurse set the IV infusion device to administer the correct amount of medication? Record your answer using a whole number. ____ mL/hr

120

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first?

Administer oxygen as prescribed.

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

A client has an IV of D5W 250 mL to which is added 100 mg of morphine. The health care provider prescribes 14 mg of morphine per hour. At how many mL per hour should the nurse set the intravenous pump? Record your answer as a whole number. ___mL/hr

35

The nurse is caring for a 75-year-old client who 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 client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?

Air will move from the lung into the pleural space.

When clients develop respiratory alkalosis, the nurse expects lab values to reflect:

An elevated pH, decreased Pco2

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

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response?

5 mm erythema with 10 mm induration

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

59-year-old who had a knee replacement

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed-chest drainage system. When caring for this client, the nurse should:

Palpate the area around the tubes for crepitus

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication?

Palpating the neck or face.

What is the major factor a nurse considers when anticipating the method of oxygen administration to be prescribed by the health care provider for a client?

Pathologic condition