Med Surg 1 Exam Herzing
A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately? "Client is drowsy and complains of headache." "Client is becoming agitated and complains of pleuritic pain." "Client has subcutaneous emphysema around needle insertion site." U"Client has oxygen saturation of 93%."
"Client is becoming agitated and complains of pleuritic pain." Rationale: After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.
The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? "I can't use a spacer or holding chamber with the MDI." "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." "I will shake the MDI container before I use it." "I will take a slow, deep breath in after pushing down on the MDI."
"I can't use a spacer or holding chamber with the MDI." Rationale: The client can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining client statements are accurate and indicate the client understands how to use the MDI correctly.
A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse? "Other symptoms you may develop are shortness of breath upon exertion and sputum production." "There are no other symptoms; however, your cough may get worse as the disease progresses." "As your COPD worsens, you will frequently develop respiratory infections." "You can also expect to experience a progressive weight gain."
"Other symptoms you may develop are shortness of breath upon exertion and sputum production." Rationale: COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Clients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. Weight loss is common with COPD.
A client has recently been diagnosed with malignant lung cancer. The nurse is calculating the client's smoking history in pack-years. The client reports smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the client's pack-years as 10 11 5 22
2 Rationale: Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day times the number of years the patient smoked. In this situation, the client's pack-years is 22 (2 × 11). It is important to find out whether the client is still smoking or when the client quit smoking.
What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration? 10 to 15 mm Hg 25 to 30 mm Hg 20 to 25 mm Hg 15 to 20 mm Hg
20 to 25 mm Hg Rationale: Usually the pressure is maintained at <25 mm HG (30 cm H2O) water pressure to prevent injury and at >20 mm HG (24 cm H2O) water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A water pressure of 10-15 or 15-20 mm Hg would indicate that the cuff is underinflated. A water pressure of 25-30 mm Hg would indicate that the cuff is overinflated.
The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent? 50% 70% 30% 90%
90% Rationale: The goal of supplemental oxygen therapy is to increase the baseline resting partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level and arterial oxygen saturation (SaO2) to at least 90%.
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside? An Ambu bag A set of hemostats A bottle of sterile water An incentive spirometer
A bottle of sterile water Rationale: It is essential that the nurse ensure that a bottle of sterile water is readily available at the client's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.
Which statement describes emphysema? Chronic dilatation of a bronchus or bronchi Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years A disease that results in reversible airflow obstruction, a common clinical outcome A disease of the airways characterized by destruction of the walls of overdistended alveoli
A disease of the airways characterized by destruction of the walls of overdistended alveoli Rationale: Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.
Which type of lung cancer is the most prevalent among both men and women? Adenocarcinoma Large cell carcinoma Small cell carcinoma Squamous cell carcinoma
Adenocarcinoma Rationale: Adenocarcinoma is most prevalent in both men and women and presents more peripherally as masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposure. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree.
A client is being treated in the ED for respiratory distress coupled with bacterial pneumonia. The client has no medical history. However, the client works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which order based on the client's immediate needs? Administration of corticosteroids and bronchodilators Completion of a 12-lead ECG Administration of antibiotics Client education: avoidance of irritants like smoke and pollutants
Administration of antibiotics Rationale: Antibiotics are administered to treat respiratory tract infections. Chronic bronchitis is inflammation of the bronchi caused by irritants or infection. Hence, smoking cessation and avoiding pollutants are necessary to slow the accelerated decline of the lung tissue. However, the immediate priority in this case is to cure the infection, pneumonia. Corticosteroids and bronchodilators are administered to asthmatic clients when they show symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.
Which is a true statement regarding air pressure variances? Air is drawn through the trachea and bronchi into the alveoli during inspiration. The thoracic cavity becomes smaller during inspiration. Air flows from a region of lower pressure to a region of higher pressure during inspiration. The diaphragm relaxes during inspiration.
Air is drawn through the trachea and bronchi into the alveoli during inspiration. Rationale: Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure.
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Increased drainage Tidaling Air leak Tension pneumothorax
Air leak Rationale: The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
Which is the strongest predisposing factor for asthma? Congenital malformations Allergy Air pollution Male gender
Allergy Rationale: Allergy is the strongest predisposing factor for asthma.
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Asking the client to say "one, two, three" while the nurse auscultates the lungs Instructing the client to take a deep breath and hold it while the diaphragm is percussed
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Rationale: While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.
The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? Instruct the client that bed rest must be maintained for 2 hours. Ensure the client remains moderately sedated to decrease anxiety. Offer the client ice chips. Assess the client for a cough reflex.
Assess the client for a cough reflex. Rationale: After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate? SIMV Assist control IMV Pressure support
Assist control Rationale: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient 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 nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort? Lay on the right side Request narcotic medication when pain is experienced Complete deep breathing exercises when chest discomfort occurs Assume a left side-lying position while in bed
Assume a left side-lying position while in bed Rationale: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" upon inspiration; clients often describe it as "like the stabbing of a knife." Clients are more comfortable when they lay on the affected side because this splints the chest wall, limits expansion and contraction of the lung, and reduces the friction between the injured or diseased pleurae on that side. Pain associated with cough may be reduced manually by splinting the rib cage. The nurse would instruct the client to lay on the left side, not the right, to decrease the pain. While pain medication may be administered, nonpharmacological therapies and nonnarcotic interventions should be implemented first. Deep breathing exercises would not help to decrease the pain, but would rather slow the client's breathing and expand the lungs.
A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?' Barrel chest Pigeon chest Kyphoscoliosis Funnel chest
Barrel chest Rationale: A barrel chest occurs as a result of over inflation of the lungs. The anteroposterior diameter of the thorax increases. Barrel chest occurs with aging and is a hallmark sign of emphysema and chronic obstructive pulmonary disease (COPD). In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge upon expiration. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.
Which type of chest configuration is typical of a client with COPD? Funnel chest Pigeon chest Flail chest Barrel chest
Barrel chest Rationale: In clients with COPD who have a primary emphysematous component, chronic hyperinflation leads to the "barrel chest" thorax configuration. This configuration results from a more fixed position of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest results from a displaced sternum. Flail chest results when the ribs are fractured. Funnel chest occurs when there is a depression in the lower portion of the sternum; it is associated with Marfan syndrome or rickets.
The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated? Heart rate less than 100 bpm PaO2 greater than 60 mm Hg with an FiO2 less than 40% Vital capacity of 12 mL/kg Blood pressure increase of 20 mm Hg from baseline
Blood pressure increase of 20 mm Hg from baseline Rationale: In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume of 7 to -9 mL/kg, minute ventilation of 6 L/min, and a rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria that indicate a client is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.
Which statement is true about both lung transplant and bullectomy? Both procedures treat patients with bullous emphysema. Both procedures improve the overall quality of life of a client with COPD. Both procedures cure COPD. Both procedures treat end-stage emphysema.
Both procedures improve the overall quality of life of a client with COPD. Rationale: Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.
Which is the most important risk factor for development of COPD? Air pollution Cigarette smoking Occupational exposure Genetic abnormalities
Cigarette smoking Rationale: Risk factors for COPD include environmental exposures and host factors. The most important environmental risk factor for COPD worldwide is cigarette smoking. A dose-response relationship exists between the intensity of smoking (pack-year history) and the decline in pulmonary function. Other environmental risk factors include smoking pipes, cigars, and other types of tobacco. Passive smoking (i.e., second-hand smoke) also contributes to respiratory symptoms and COPD. Air pollution and genetic abnormalities are risk factors for development of COPD, but neither is the most important.
The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the client's mouth with chlorhexidine daily Ensuring that the client remains sedated while intubated Turning and repositioning the client every 4 hours Maintaining the client in a high Fowler's position
Cleaning the client's mouth with chlorhexidine daily Rationale: The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.
Which drug is second-line pharmacotherapy for smoking abstinence whose side effects limit its use? Nortriptyline Nicotine gum Bupropion SR Clonidine
Clonidine Rationale: Second-line pharmacotherapy includes the antihypertensive agent clonidine. However, its use is limited by its side effects. First-line therapy includes nicotine gum, nortriptyline, and bupropion SR.
The nurse is reviewing first-line pharmacotherapy for smoking abstinence with a client diagnosed with COPD. The nurse correctly includes which medications? Select all that apply. Clonidine Caffeine Nicotine gum Acetaminophen Bupropion SR
Clonidine, Nicotine gum, Bupropion SR Rationale: First-line therapy includes nicotine gum as well as the antidepressants bupropion SR and nortriptyline. Second-line pharmacotherapy includes the antihypertensive agent clonidine. However, the use of clonidine is limited by its side effects. Varenicline, a nicotinic acetylcholine receptor partial agonist, may also assist in smoking cessation.
Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process? Bronchiectasis Atelectasis Consolidation Empyema
Consolidation Rationale:Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.
Which medication is contraindicated in acute asthma exacerbations? Albuterol Ipratropium bromide Cromolyn sodium Levalbuterol
Cromolyn sodium Rationale: Cromolyn sodium is contraindicated in clients with acute asthma exacerbation.
The nurse is caring for a client with extensive respiratory disease. Which is a late sign of hypoxia the client may experience? Hypotension Cyanosis Somnolence Restlessness
Cyanosis Rationale:Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus? Normal perfusion-to-ventilation ratio Low ventilation-perfusion ratio Dead space Silent unit
Dead space Rationale: A dead space exists when ventilation exceeds perfusion (high ventilation-perfusion ratios). An example of a dead space is a pulmonary embolus, pulmonary infarction, and cardiogenic shock. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or acute respiratory distress syndrome.
An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion? Wheezing upon auscultation Resonance upon percussion Decreased chest wall excursion upon palpation Mottled skin seen during inspection
Decreased chest wall excursion upon palpation Rationale: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound upon percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.
Which is an age-related change associated with the respiratory system? Increased chest muscle mass Thinning of alveolar membranes Increased elasticity of alveolar sacs Decreased size of the airway
Decreased size of the airway Rationale: Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea? Color of the mucous membranes Evidence of muscle weakness Deviation from the midline Evidence of exudate
Deviation from the midline Rationale: During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.
High or increased compliance occurs in which disease process? Emphysema Pleural effusion Pneumothorax ARDS
Emphysema Rationale: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).
Which intervention does a nurse implement for clients with empyema? Do not allow visitors with respiratory infections Institute droplet precautions Encourage breathing exercises Place suspected clients together
Encourage breathing exercises Rationale: Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.
Which exposure accounts for most cases of COPD? Ambient air pollution Passive smoking Exposure to tobacco smoke Occupational exposure
Exposure to tobacco smoke Rationale: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.
In which grade of COPD is the forced expiratory volume in 1 second (FEV1) less than 30% predicted? I III II IV
IV Rationale: COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.
A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action? If coughing occurs during the procedure, repeat it. Move the indicator to the top of the numbered scale. Take and record peak flow readings three times daily. Sit down while completing a peak flow reading.
If coughing occurs during the procedure, repeat it. Rationale:Steps for using the peak flow meter correctly include (1) moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing the mouthpiece in the mouth and closing the lips around it; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the client coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.
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? Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the strengthening of the client's diaphragm Promote the client's ability to take in oxygen Promote more efficient and controlled ventilation and to decrease the work of breathing
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Rationale: 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.
Bradypnea is associated with which condition? Pneumonia Increased intracranial pressure Pulmonary edema Metabolic acidosis
Increased intracranial pressure Rationale: Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea is commonly seen in clients with pneumonia, pulmonary edema, and metabolic acidosis.
Which measure may increase complications for a client with COPD? Increased oxygen supply Administration of antibiotics Decreased oxygen supply Administration of antitussive agents
Increased oxygen supply Rationale: Administering too much oxygen can result in the retention of carbon dioxide. Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs. All the other measures aim to prevent complications.
Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation? Expiratory reserve volume Inspiratory reserve volume Residual volume Tidal volume
Inspiratory reserve volume Rationale: Inspiratory reserve volume is normally 3000 mL. Tidal volume is the volume of air inhaled and exhaled with each breath. Expiratory reserve volume is the maximum volume of air that can be exhaled forcibly after a normal exhalation. Residual volume is the volume of air remaining in the lungs after a maximum exhalation.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Administer a large dose of furosemide (Lasix) IVP stat Increase oxygen administration Schedule the client for pulmonary surgery
Intubate the client and control breathing with mechanical ventilation Rationale: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report? Bronchitis Left-sided heart failure Emphysema Chronic obstructive pulmonary disorder (COPD)
Left-sided heart failure Rationale :Coughing at night may indicate the onset of left-sided heart failure or bronchial asthma. A cough in the morning with sputum production may indicate bronchitis. A cough that worsens when the client is supine suggests postnasal drip (rhinosinusitis). Coughing after food intake may indicate aspiration of material into the tracheobronchial tree. A cough with recent onset is usually caused by an acute infection. A cough that occurs more frequently at night is not associated with COPD, emphysema, or bronchitis.
Why would a client with COPD report feeling fatigued? Select all that apply. Lung function gradually decreases over time in clients with COPD. Muscle function gradually decreases over time in clients with COPD. The client is using all expendable energy just to breathe. The client is using all expendable energy for activities of daily living (ADLs).
Lung function gradually decreases over time in clients with COPD., The client is using all expendable energy just to breathe. Rationale: The client is using all expendable energy just to breathe. Lung function, not muscle function, gradually decreases over time in clients with COPD. In a client with COPD, fatigue and a feeling of exhaustion stem directly from the disease, not from activity level.
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? Hypoxemia Dyspnea Orthopnea Hemoptysis
Orthopnea Rationale: Orthopnea is the term used to describe a client's inability to breathe easily except in an upright position. Orthopnea may occur in clients with heart disease and, occasionally, in clients with COPD. Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.
Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies? Gallium scan Pulmonary angiography PET MRI
PET Rationale: PET is more accurate in detecting malignancies than CT, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thoracoscopy. A gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs.
The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan? Discussing palliative care and end-of-life issues with the client Restricting oral intake to 1,000 mL/day Providing the client a low-sodium diet Performing chest physiotherapy as ordered
Performing chest physiotherapy as ordered Rationale: Nursing care includes helping clients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Clients with CF also experience increased salt content in sweat gland secretions; thus it is important to ensure the client consumes a diet that contains adequate amounts of sodium. As the disease progresses, the client will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the client is terminally ill.
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide Puts on clean gloves; removes and discards the soiled dressing in a biohazard container
Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Rationale: For a new tracheostomy, two people should assist with tie changes to help make sure the new tracheostomy is not dislodged. A dislodged tracheostomy is a medical emergency. The other actions, if performed by the nurse during tracheostomy care, are correct. The wound and plate should be cleaned with sterile cotton-tipped applicators moistened with saline or sterile water or with hydrogen peroxide if infection is present. The inner cannula should be dried before reinsertion or if a disposable is being used, a new disposable cannula should be reinserted. The nurse should put on clean gloves and discard the soiled dressing in a biohazard container.
In general, chest drainage tubes are not indicated for a client undergoing which procedure? Pneumonectomy Lobectomy Segmentectomy Wedge resection
Pneumonectomy Rationale: Usually no drains are used in pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.
In COPD, the body attempts to improve oxygen-carrying capacity by increasing the amount of red blood cells. Which term refers to this process? Emphysema Polycythemia Asthma Bronchitis
Polycythemia Rationale: Polycythemia is an increase in the red blood cell concentration in the blood. In COPD, the body attempts to improve oxygen-carrying capacity by producing increasing amounts of red blood cells.
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client? Administer small doses of pancuronium Position the client in the prone position Force fluids for the next 24 hours Assist the client into a chair
Position the client in the prone position Rationale: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs.
In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply. Prednisone is a corticosteroid. Ciprofloxacin is an antibiotic. Albuterol is a bronchodilator. Cotrimoxazole is a bronchodilator. Dexamethasone is an antibiotic.
Prednisone is a corticosteroid., Ciprofloxacin is an antibiotic., Albuterol is a bronchodilator. Rationale: Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and cotrimoxazole are antibiotics. All of these drugs could be prescribed to a client with COPD.
A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply. Condition the inspiratory muscles Prevent airway collapse Release air trapped in the lungs Control the rate and depth of respirations Strengthen the diaphragm
Prevent airway collapse, Release air trapped in the lungs, Control the rate and depth of respirations Rationale: The nurse is teaching the client the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases air trapped in the lungs, and helps the client control the rate and depth of respirations. This helps clients relax and get control of dyspnea and reduces the feelings of panic they may experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training, the client will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.
A client presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands that goals of therapy should be achieved to improve the client's condition. Which statements reflect therapy goals? Select all that apply. Provide medical support for the current exacerbation. Treat the underlying cause of the event. Teach the client to suspend activity. Return the client to their original functioning abilities. Provide long-term support for medical management.
Provide medical support for the current exacerbation., Treat the underlying cause of the event., Return the client to their original functioning abilities., Provide long-term support for medical management. Rationale: The goal is to have a stable client with COPD leading the most productive life possible. COPD cannot necessarily be cured, but it can be managed so that the client can live a reasonably normal life. With adequate management, clients should not have to give up their usual activities.
Which diagnostic test is the most accurate in assessing acute airway obstruction? Pulmonary function studies Arterial blood gases (ABGs) Pulse oximetry Chest x-ray
Pulmonary function studies Rationale: Pulmonary function studies are the most accurate means of assessing acute airway obstruction. ABGs, pulse oximetry, and chest x-ray are not the most accurate diagnostics for an airway obstruction.
Which diagnostic test is most accurate in assessing acute airway obstruction? Arterial blood gases (ABGs) Pulse oximetry Spirometry Pulmonary function studies
Pulmonary function studies Rationale: Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs and pulse oximetry are not the most accurate diagnostics for an airway obstruction. Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC).
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Bilateral wheezing Inspiratory crackles Cyanosis Rapid onset of severe dyspnea
Rapid onset of severe dyspnea Rationale: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Receiving vaccinations Using prescribed opioids Using incentive spirometry Mobilizing early
Receiving vaccinations Rationale: Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? Apply a compression dressing to the area Record the observation Report the finding to the physician immediately Measure the patient's pulse oximetry
Record the observation Rationale: The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis
Respiratory acidosis Rationale: As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Deflating the cuff before removing the tube Routinely deflating the cuff Ensuring that humidified oxygen is always introduced through the tube Checking the cuff pressure every 6 to 8 hours
Routinely deflating the cuff Rationale: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? Shortness of breath Headache Fever Weight loss
Shortness of breath Rationale: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.
The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? Prone Supine Lateral recumbent Sitting on the edge of the bed
Sitting on the edge of the bed Rationale: If possible, it is best to place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).
A client involved in a motor vehicle crash suffered a penetrating injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax? Sucking sound at the site of injury Diminished breath sounds Decreased respiratory rate Bloody, productive cough
Sucking sound at the site of injury Rationale: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed "sucking chest wounds." Diminished breath sounds are common in a simple pneumonthorax or when there is tension in the lungs. Respiratory rate is usually increased as the individual is trying to componsate for the lack of oxygen entering the blood stream. A bloddy, productive cough is not usually seen with a pneumothorax.
For which reason does gas exchange decrease in older adults? The elasticity of the lungs increases with age. The alveolar walls become thicker. The number of alveoli decreases with age. The alveolar walls contain fewer capillaries.
The alveolar walls contain fewer capillaries. Rationale: Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and the number of alveoli does not decrease with age.
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate? Emphysema Trauma Malignancy Infection
Trauma Rationale: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. The fluid, which may be clear, serous, bloody, or purulent, provides clues to the pathology. Bloody fluid may indicate trauma, whereas purulent fluid usually indicates an infection and serous fluid indicates malignancy or heart failure. Pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infection are complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated.
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that they will be safe from infecting others approximately how long after initiation of the medication therapy? Two to 3 weeks after initiation of bactericidal drugs Results vary with each client, so it is difficult to predict After completion of 6 months of bactericidal drugs Within 48 hours after initiation of bactericidal drugs
Two to 3 weeks after initiation of bactericidal drugs Rationale: The client needs to take the prescribed medications for approximately 2 to 3 weeks before discontinuing precautions against infecting others. Effectiveness of the drug therapy is determined by negative sputum smears obtained on three consecutive days. Although results can vary among clients, the majority respond to therapy within 2 to 3 weeks.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Volume cycled Negative pressure Pressure cycled Time cycled
Volume cycled Rationale: 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.
Which of the following is not a primary symptom of COPD? Weight gain Cough Sputum production Dyspnea upon exertion
Weight gain Rationale: COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Weight loss is common with COPD.
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 low in fat by limiting dairy products and concentrated sweets." "You must consume a diet rich in protein, such as chicken, fish, and beans." "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." Rationale: 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 client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes instructing the client on the signs of respiratory infection. providing the client a low-calorie, high-fiber diet. implementing measures to clear pulmonary secretions. teaching the family how to perform postural drainage.
implementing measures to clear pulmonary secretions. Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Although teaching the family how to perform postural drainage and instructing the client on the signs of respiratory infection are important, they are not the nurse's primary focus. The presence of a large amount of mucus may decrease the client's appetite and result in inadequate dietary intake; therefore, the client's nutritional status is assessed and strategies are implemented to ensure an adequate diet.
The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the rectum. stomach. nose. lungs.
lungs. Rationale: Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.
The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a client with a respiratory disorder in a way that manages decreased energy levels. ensures adequate rest periods. aid the client's caregivers. manages respiratory distress.
manages decreased energy levels. Rationale: In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.
The classification of grade I COPD is defined as severe COPD. moderate COPD. mild COPD. very severe COPD.
mild COPD. Rationale: Grade I is mild COPD. Grade II is moderate COPD. Grade III is severe COPD. Grade IV is very severe COPD.
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? pH 7.87, PaCO2 38, HCO3 28 pH 7.47, PaCO2 28, HCO3 30 pH 7.25, PaCO2 48, HCO3 24 pH 7.49, PaCO2 34, HCO3 25
pH 7.25, PaCO2 48, HCO3 24 Rationale: pH less than 7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2 38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate respiratory alkalosis.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.35, PaCO2 48 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.46, PaO2 80 mm Hg
pH 7.28, PaO2 50 mm Hg Rationale: ARF 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 >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as crackles. pleural friction rub. sonorous wheezes. sibilant wheezes.
pleural friction rub. Rationale: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.
Pink, frothy sputum may be an indication of an infection. a lung abscess. pulmonary edema. bronchiectasis.
pulmonary edema. Rationale: Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client requiring sedation until the chest tube(s) are removed. returning to the nursing unit with two chest tubes. requiring mechanical ventilation following surgery. returning from surgery with no drainage tubes.
returning to the nursing unit with two chest tubes. Rationale: The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.
A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include monitoring liver function studies as prescribed. development of hyperkalemia. the importance of blood tests to monitor serum concentrations. taking the medication at least 1 hour prior to meals.
the importance of blood tests to monitor serum concentrations. Rationale: The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.
In relation to the structure of the larynx, the cricoid cartilage is the only complete cartilaginous ring in the larynx. the valve flap of cartilage that covers the opening to the larynx during swallowing. used with the thyroid cartilage in vocal cord movement. the largest of the cartilage structures.
the only complete cartilaginous ring in the larynx. Rationale: The cricoid cartilage is located below the thyroid cartilage. The arytenoid cartilages are used with the thyroid cartilage in vocal cord movement. The thyroid cartilage is the largest of the cartilage structures and part of it forms the Adam's apple. The epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing.
The term for the volume of air inhaled and exhaled with each breath is residual volume. vital capacity. tidal volume. expiratory reserve volume.
tidal volume. Rationale: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.
