Med- Surg II - Respiratory
A nurse in emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first. Apply supplemental oxygen. Increase the rate of IV fluids. Administer pain medication. Initiate cardiac monitoring.
Apply supplemental oxygen When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and new prescription for rifampin. Which of the following instructions should the nurse include? "Ringing in the ears is an adverse effect of this medication." "Have your skin test repeated in 4 months to show a positive result." "Expect your urine and other secretions to be orange while taking this medication." "Remember to take this medication with a sip of water just before your first bite of each meal."
"Expect your urine and other secretions to be orange while taking this medication." orange discoloration of bodily fluids (sputum, urine, sweat, tears) Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur including jaundice, fatigue or malaise.
A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method For the nurse to use to determine the effectiveness of the current treatment regimen? Blood pressure Capillary refill Arterial blood gases Heart rate
Arterial blood gases When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.
A nurse providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." "I should remove the old twill ties after the new ties are in place." "I should apply suction while inserting the catheter into my tracheostomy tube."
"I should remove the old twill ties after the new ties are in place." As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.
A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? "I will monitor my heart rate every day while taking this medication." "I will make sure I have this medication with me at all times." "I will need to carefully rinse my mouth after I take this medication." "I will take this medication every night even if I don't have symptoms."
"I will take this medication every night even if I don't have symptoms." Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.
A nurse received prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A client who has epistaxis A client who has amyotrophic lateral sclerosis A client who has pneumonia A client who has emphysema
A client who has epistaxis The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.
A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A client who is 48 hr postoperative following a total hip arthroplasty A client who is 8 hr postoperative following an open surgical appendectomy A client who is 2 hr postoperative following an open reduction external fixation of the right radius A client who is 4 hr postoperative following a laparoscopic cholecystectomy
A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that the client who has undergone a total hip replacement surgery is at greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devises or antiembolic stockings and by administering anticoagulant medications.
Which statement is true regarding a flutter valve? A flutter valve allows patient mobility. A flutter valve is used to evacuate fluid from the pleural space. A flutter valve is attached to the internal end of the chest tube. A flutter valve opens when the chest pressure is less than atmospheric pressure.
A flutter valve allows patient mobility. Rationale A flutter valve or Heimlich valve allows for patient mobility, as the smaller drainage bag can be hidden under the clothes while the patient ambulates. The valve evacuates air, not fluid, from the pleural space. It is attached to the external end of the chest tube. A flutter valve opens whenever the pressure in the chest is greater than the atmospheric pressure. p. 522
Which patient can be treated with a tissue plasminogen activator? A patient with atelectasis A patient with sarcoidosis A patient with right ventricular dysfunction A patient with idiopathic pulmonary fibrosis
A patient with right ventricular dysfunction Tissue plasminogen activator is a fibrinolytic (alteplase) agent that dissolves the pulmonary embolus and thrombus in deep veins and can be used in the patient with right ventricular dysfunction. Atelectasis is treated with bronchodilators, and sarcoidosis can be effectively treated with antiinflammatory agents. Idiopathic pulmonary fibrosis is effectively treated with oxygen therapy and lung transplantation. pp. 529-531
A patient with New York Heart Association (NYHA) class III right-sided heart failure has an oxygen saturation of 75 percent. Which medication therapy would be beneficial to this patient? Diltiazem Adenosine Prednisolone Mycophenolatemofetil
Adenosine Rationale Adenosine may be beneficial for a patient with New York Heart Association (NYHA) class III right-sided heart failure, whose oxygen saturation is 75 percent, because adenosine is a prostacyclin analog that promotes pulmonary vasodilation and reduces pulmonary vascular resistance. Diltiazem is a calcium channel blocker that should be used in a patient without right-sided heart failure because it may deteriorate the patient's condition. Prednisolone and mycophenolatemofetil are immunosuppressants that are used to prevent graft rejection in lung transplant patients. p. 532
A nurse caring for a clinet hwo has a pulmonary embolism. Which of the following intervention is the priority? Provide a quiet environment. Encourage use of incentive spirometry every 1 to 2 hr. Obtain a blood sample for electrolyte study. Administer heparin via continuous IV infusion.
Administer heparin via continuous IV infusion. Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should be implemented? Airborne Neutropenic Contact Droplet
Airborne The nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter. Members of the healthcare team should not enter the client's room without wearing an N95 respirator mask.
A nurse is planning care for a client who has asthma. Which of the following medication should the nurse plan to administer during an acute asthma attack? Cromolyn sodium Prednisone Fluticasone/salmeterol Albuterol
Albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.
Which drug is effective in treating New York Heart Association (NYHA) class II right-sided heart failure? Sildenafil Nifidipine Treprostinil Ambrisentan
Ambrisentan Ambrisentan is an endothelin receptor antagonist that is used in the treatment of New York Heart Association (NYHA) class II to IV right-sided heart failure, because it increases the cardiac index. Sildenafil is used in the treatment of pulmonary hypertension only. Nifidipine and treprostinil are used in the treatment of NYHA class III and IV right-sided heart failure. p. 532
A patient with hypoxemia, sudden alterations in mental status, chest pain, and hemoptysis has a serum troponin level of 2.08 ng/mL and B type natriuretic peptide of 600 pg/mL. Which treatment is useful to control this patient's condition? Diuretics Anticoagulants Endothelin receptor antagonists Nonsteroidal antiinflammatory agents
Anticoagulants Hypoxemia, sudden alterations in mental status, chest pain, and hemoptysis are manifestations of pulmonary embolism. Serum troponin of 2.08 ng/mL (normal value: below 0.01 to 0.09 ng/mL) and B type natriuretic peptide of 600 pg/mL (normal value: below 100 pg/mL) indicates increased mortality. Therefore anticoagulants may provide relief from the symptoms by dissolving the embolus. Diuretics are beneficial in patients with pleural effusion and heart failure. Endothelin receptor antagonists are used in the treatment of pulmonary hypertension because they reduce pulmonary arterial pressure and pulmonary vascular resistance. Nonsteroidal antiinflammatory agents are used in the treatment of pleurisy to reduce chest pain. pp. 529-530
A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as the possible cause of the alarm? Excess secretions Kinks in the tubing Artificial airway cuff leak Biting on the endotracheal tube
Artificial airway cuff leak- An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound. An excess of secretions in the airway causes the high pressure alarm to sound. Kinks in the tubing can cause an obstruction, which causes the high pressure alarm to sound. Biting on the endotracheal tube causes the high pressure alarm to sound.
A nurse is assessing the pulmonary functions of a patient and finds that the vital capacity and total lung capacity are reduced. What respiratory disorders could cause the reduced capacities? Select all that apply. Asthma Atelectasis Emphysema Chronic bronchitis Pulmonary fibrosis
Atelectasis Pulmonary fibrosis Pulmonary function tests are used to differentiate restrictive pulmonary disorders from obstructive disorders. Reduction in vital capacity and total lung capacity indicates that the patient has restrictive pulmonary disorder. Both atelectasis and pulmonary fibrosis are examples of restrictive disorders. Emphysema, chronic bronchitis, and asthma are obstructive pulmonary disorders and are highly unlikely to be seen in this patient. p. 527
A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect? Blood-tinged sputum Decreased tactile fremitus Resonance with percussion Pericardial edema
Blood-tinged sputum The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.
The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now the patient is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)
Bronchiolitis obliterans (BOS) Rationale BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily caused by parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection one to four months after lung transplant. p. 534
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider? Fluctuation of drainage in the tubing with inspiration Continuous bubbling in the water seal chamber Drainage of 75 mL in the first hour after surgery Several small, dark-red blood clots in the tubing
Continuous bubbling in the water seal chamber Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider. Fluctuation of drainage in the tubing with inspiration is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client; however, this finding does not require intervention by the nurse. Drainage of 75 mL in the first hour after surgery is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client, but intervention by the nurse is not required at this time. Small, dark-red clots are an expected finding for a client after chest surgery. The nurse should continue to monitor the client, but intervention by the nurse is not required at this time.
A nurse is assessing a client who is 4 hr post-op following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? Bleeding at the surgical site Decreased oxygen saturation Urinary retention Increased pain level
Decreased oxygen saturation Using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction.
The nurse is caring for the patient with pulmonary hypertension. Which treatment(s) are appropriate? Select all that apply. Diuretics Vasodilators Thrombolytics Anticoagulants
Diuretics Vasodilators Anticoagulants Vasodilators, diuretics, and anticoagulants are correct because they are included in drug treatments for pulmonary hypertension. Vasodilators are especially important in the treatment of pulmonary hypertension because they will aid in reducing the right ventricular workload by dilating pulmonary vessels. Diuretics decrease plasma volume and thereby reduce myocardial workload. Anticoagulants also are used, especially if the case is severe, because they work to prevent in situ thrombus formation and venous thrombosis. Warfarin would be given to keep the international normalized ratio (INR) in the 2 to 3 range. Thrombolytic therapy is not an appropriate drug treatment and would be used if the condition caused right ventricle hypertrophy, resulting in cor pulmonale. pp. 531-532
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? Rhonchi on inspiration Elevated temperature Barrel-shaped chest Diminished breath sounds
Elevated temperature The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.
Which type of chest surgery is indicated for a patient with chest trauma? Pneumonectomy Segmental resection Exploratory thoracotomy Lung volume reduction surgery
Exploratory thoracotomy Exploratory thoracotomy is indicated for a patient with chest trauma. Pneumonectomy is indicated for a patient with lung cancer. Segmental resection is indicated for a patient with bronchiectasis. Lung volume reduction surgery is indicated for a patient with advanced bullous emphysema. p. 526
A patient with dyspnea, cough, chest pain, and a body temperature of 101° F has crackling and wheezing sounds upon auscultation. Which treatment strategy provides comfort to this patient? Diuretics Corticosteroids Fibrinolytic agents Endothelin receptor antagonists
Fibrinolytic agents Dyspnea, cough, chest pain, and fever associated with crackling, wheezing, and accentuation of the pulmonic heart sound upon auscultation may indicate pulmonary embolism. Fibrinolytic agents dissolve the pulmonary embolus and decrease the chances of recurrent emboli. Diuretics are not used, because the patient does not have fluid accumulated in the pleural space. Corticosteroids are helpful to treat inflammatory pulmonary disorders like sarcoidosis. Endothelin receptor antagonists are efficient at reducing arterial pressure and are used in the treatment of pulmonary hypertension. p. 530
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? Lateral position with a pillow at the back and over the chest to support the arm High-Fowler's position with the arms supported on the over-bed table Semi-Fowler's position with pillows supporting both arms Supine position with the head of the bed elevated to 15°
High-Fowler's position with the arms supported on the over-bed table The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the over-bed table.
A patient with syncope and dyspnea has a systolic blood pressure of 70 mm Hg. The pulmonary artery pressure is 35 mm Hg after exercise. Which medication may worsen this patient's condition? Iloprost Tacrolimus Prednisolone Methotrexate
Iloprost A patient with syncope, dyspnea, and a pulmonary artery pressure of 35 mm Hg after exercise may have pulmonary hypertension. Vasodilators, such as iloprost, may comfort the patient, but it should not be given when the systolic blood pressure is 70 mm Hg because it may lead to orthostatic hypotension. Tacrolimus and prednisolone are immunosuppressive agents that help prevent graft rejection in lung transplant patients. Methotrexate may be used to relieve the symptoms of idiopathic pulmonary fibrosis. p. 532 The patient has a systolic blood pressure less than 85 mm Hg, which may result in hypotension. Select the correct medication that is not advised for this patient.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to provider? Decreased bowel sounds Oxygen saturation 92% CO2 24 mEq/L Intercostal retractions
Intercostal retractions The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.
The nurse is assessing a patient who has a closed chest tube drainage system attached to a water-seal chamber. The nurse notes that the tidaling has stopped. What is the priority intervention by the nurse? Continue to monitor the patient. Check all connections for a leak in the system. Investigate the chest tube for a possible occlusion. Lower the drainage collector further from the chest.
Investigate the chest tube for a possible occlusion. Normal fluctuation of the water within the water-seal chamber is called tidaling. This up and down movement of water in concert with respiration reflects the intrapleural pressure changes during inspiration and expiration. Investigate any sudden cessation of tidaling because this may signify an occluded chest tube. Monitoring the patient will occur simultaneously. The nurse could check all connections for a leak, but the most common cause is occlusion, so this would occur after checking for an occlusion. The drainage collector is likely already in a low position. p. 525
A patient is admitted to the hospital after being involved in a motor vehicle accident. The patient has asymmetric chest excursion and an absence of breath sounds on the left side. The nurse suspects what? Left pneumothorax Right pneumothorax Pulmonary embolism Adult respiratory distress syndrome
Left pneumothorax When the left part of the chest is crushed, breathing is compromised and asymmetric excursion is seen. This information, along with the absence of breath sounds, is an indication of a left pneumothorax. The injury is located on the left side of the chest. Pulmonary embolism does not present with the given history. There is not enough information to conclude that adult respiratory distress syndrome (ARDS) has developed. Risk for ARDS is greater after the initial injury, not at the time of the injury. p. 519
Which type of surgery involves the removal of one lobe of lung? Lobectomy Pneumonectomy Wedge resection Segmental resection
Lobectomy A lobectomy is a type of chest surgery that involves removal of one lobe of lung. A pneumonectomy is a type of chest surgery that involves removal of entire lung. A wedge resection is a type of surgery that involves removal of only a small, localized lesion. A segmental resection is a type of surgery that involves removal of one or more lung segments. p. 516
A nurse is caring for a client who is in respiratory distress. Whcih of the followinf low-flow delivery devied should the nurse use to provide the highest lever of O2? Nasal cannula Nonrebreather mask Simple face mask Partial rebreather mask
Nonrebreather mask The nurse should use a non-rebreather mask for a client in respiratory distress to provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.
A nurse in ED is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory finding should the nurse expect? Arterial pH 7.50 PaCO2 25 mm Hg SaO2 92% PaO2 58 mm Hg
PaO2 58 mm Hg The nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen.
A nurse is caring for a client who is 1 hr post-op following a thoracentesis. Which of the following is the priority assessment finding? Pallor Insertion site pain Persistent cough Temperature 37.3° C (99.1° F)
Persistent cough When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is persistent cough because this indicates a tension pneumothorax, which is a medical emergency.
The nurse is caring for a patient with right ventricular hypertrophy and a hematocrit of 70 percent. The nurse finds an increase in S 2 upon auscultation. Which treatment strategy does the nurse anticipate will benefit this patient? Phlebotomy Embolectomy Lung transplantation Inferior vena cava filter
Phlebotomy Rationale Right ventricular hypertrophy, hematocrit of 70 percent, and prominent S 2 may indicate cor pulmonale. A patient with chronic cor pulmonale may have increased S 2 and polycythemia due to a primary disorder of the respiratory system. This must be treated with phlebotomy. Embolectomy is used in the treatment of pulmonary embolism to remove the deep vein thrombus. Lung transplantation is indicated for patients with severe lung disorder. An inferior vena cava filter is used to filter out the large clots that block pulmonary circulation. T
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments. Presence of gag reflex Pain level rating using a 0-10 scale Hydration status Appearance of the IV insertion site
Presence of gag reflex The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.
A nurse is a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider. Increased anterior-posterior chest diameter Productive cough with green sputum Clubbing of the fingers Pursed-lip breathing with exertion
Productive cough with green sputum When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.
A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? Schedule respiratory treatments following meals. Have the client sit up in a chair for 2-hr periods three times per day. Provide a diet that is high in calories and protein. Combine activities to allow for longer rest periods between activities.
Provide a diet that is high in calories and protein. - The nurse should provide the client who has COPD with a diet that is high in calories and protein and low in carbohydrates. The nurse should schedule activities that are short in duration with adequate rest periods in between to prevent fatigue. The nurse should provide short periods of activity frequently throughout the day. The nurse should schedule respiratory treatments before meals.
The nurse provides preprocedure teaching for a patient who is scheduled for bedside thoracentesis. What does the nurse explain to be the primary purpose of thoracentesis? Determining the stage of a lung tumor Directly inspecting and examining the pleural space Obtaining a specimen of pleural tissue for evaluation Relieving an abnormal accumulation of fluid in the pleural space
Relieving an abnormal accumulation of fluid in the pleural space Rationale Thoracentesis involves the insertion of a large-bore needle into the pleural space to relieve an abnormal accumulation of fluid in the pleural space. The procedure can significantly relieve symptoms related to this fluid accumulation, such as shortness of breath and discomfort. Thoracentesis cannot reveal the stage of lung cancer or permit direct inspection and examination of the pleural space. It may provide a pleural fluid specimen but not a pleural tissue specimen. pp. 527-528
The nurse is assessing a patient with cor pulmonale, a distended neck vein, and an enlarged liver, whose computer tomography report reveals clear fluid accumulation in the pleural space. Which intervention by the nurse provides stabilization of this patient's condition? Restricting sodium diet Monitoring for infection Monitoring liver functioning Position the patient at a 45-degree angle
Restricting sodium diet A patient with cor pulmonale, enlargement of the right ventricle, with distention of the neck vein, enlarged liver, and clear fluid accumulated in the pleural space may have heart failure. The patient with heart failure is treated with diuretics and a low sodium diet to decrease the incidence of pleural effusion and to reduce workload on the heart. The patient with a liver transplant should be monitored for infection that may lead to death. The patient on endothelin receptor antagonists to correct pulmonary hypertension should be monitored for liver functioning every month. Making the patient sit at a 45-degree angle may not benefit the patient; the patient may be treated with long-term oxygen therapy. This helps to reduce hypoxemia and vasoconstriction. p. 533
What is the most evident symptom of flail chest in an unconscious patient? Cyanosis Shallow respiration Distension of neck vein Symmetric movement of thorax
Shallow respiration An unconscious patient who has fractures of consecutive ribs will have rapid and shallow respirations. Cyanosis may occur in a patient with impaired respiration; however, it is not an evident symptom of flail chest. The patient with flail chest will not have edema, so distension of the neck is not apparent. The patient with flail chest will have asymmetric movement of the thorax due to poor air movement. pp. 521-522
A patient with heart failure has a pulmonary arterial pressure of 28 mm Hg when at rest. Which intervention helps in comforting this patient? Supplying oxygen to the patient Infusing intravenous fluids to the patient Applying warm and cold compress to the patient Positioning the patient at an angle of 90 degrees
Supplying oxygen to the patient A patient with heart failure and a pulmonary arterial pressure of 28 mm Hg when at rest may have pulmonary hypertension. This may lead to hypoxia; therefore, the patient must be supplied with low oxygen flow to provide symptomatic relief. Positioning the patient at an angle of 90 degrees indicates full Fowler's position, which may exacerbate symptoms in this patient. Intravenous fluid infusion may not relieve the patient's symptoms. Warm and cold compresses may benefit the patient with chest pain. p. 531-533
A nurse is assessing a client who has bacterial pneumonia.. Which of the following clinical manifestations should the nurse expect? Decreased fremitus SaO2 95% on room air Temperature 38.8° C (101.8° F) Bradypnea
Temperature 38.8° C (101.8° F) An elevated temperature is an expected finding for a client who has bacterial pneumonia.
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client Extra drainage system Suture removal set Container of sterile water Nonadherent pads
The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? Hyperkalemia Dyspnea Tachycardia Candidiasis
The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.
A nurse working in ED is caring for a client following an acute chest trauma. Which of the following findings indicated to the nurse the client is possibly experiencing a tension pneumothroax? Collapsed neck veins on the affected side Collapsed neck veins on the unaffected side Tracheal deviation to the affected side Tracheal deviation to the unaffected side
The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
A patient with chronic obstructive pulmonary disorder is considered for lung transplantation. The patient had melanoma and hepatitis A one year ago. The patient previously smoked three cigarettes per day but has not smoked in the past year. The nurse considers the patient's history and concludes what about the patient's eligibility for lung transplantation? The patient is eligible for lung transplantation. Because of the history of smoking, the patient is not eligible. Because of the history of hepatitis A, the patient is not eligible. Because of the history of cancer one year ago, the patient is not eligible.
The patient is eligible for lung transplantation. Chronic obstructive pulmonary disease is one of the indications for lung transplantation. There are some absolute contraindications for lung transplantation, including but not limited to being a current smoker, chronic active hepatitis B or C, history of cancer except skin cancer, poor nutritional status, and HIV. This patient is eligible for lung transplantation. The patient is not a current smoker, has hepatitis A, and had melanoma, which is a skin cancer. Therefore there are no contraindications for lung cancer. pp. 533-534
Which wound is described as a penetrating trauma on the chest wall? Wound caused by gunshot Wound caused by crush injury Wound caused by pedestrian accident Wound caused by motor vehicle accident
The wound caused by a gunshot is a penetrating trauma because it is an open injury into which a foreign object enters into the body. A wound caused by a motor vehicle accident, a crush injury, or a pedestrian accident are blunt injuries. p. 519
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? Use clean technique when suctioning the client's endotracheal tube. Use a rotating motion when removing the suction catheter. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube. Suction the client's endotracheal tube every 2 hr.
Use a rotating motion when removing the suction catheter. The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma.
Which type of surgery allows the surgeon to manipulate instruments passed into the pleural space? Decortication Segmental resection Exploratory thoracotomy Video-assisted thoracoscopic surgery
Video-assisted thoracoscopic surgery Video-assisted thoracoscopic surgery allows the surgeon to manipulate instruments passed into pleural space. Decortication, segmental resection, and exploratory thoracotomy do not allow the surgeon to manipulate instruments passed into pleural space. p. 526
A nurse is assisting the provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (select all that apply) Wear goggles and mask during the procedure. Cleanse the procedure area with an antiseptic solution. Instruct the client to take deep breaths during the procedure. Position the client laterally on the affected side before the procedure. Apply pressure to the site after the procedure.
Wear goggles and mask during the procedure. Cleanse the procedure area with an antiseptic solution. Apply pressure to the site after the procedure. Wear goggles and mask during the procedure is correct. The nurse and provider should wear goggles and a mask to reduce the risk of exposure to pleural fluid. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk of infection, which is increased due to the invasive nature of the procedure. Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk of puncturing the pleura or lung. Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk of bleeding at the procedure site.
The nurse is caring for a patient with blood dyscrasias whose arterial blood gas saturation is 75 percent. The nurse hears crackles, wheezes, and accentuation of the pulmonic heart sound upon auscultation. Which treatment strategy would be beneficial for this patient? Thoracentesis Intercostal nerve block Inferior vena cava filter Pulmonary embolectomy
inferior vena cava filter An oxygen saturation level of 75 percent (hypoxemia) associated with crackles, wheezes, and accentuation of the pulmonic heart sound may be manifestations of pulmonary embolism. For patients with blood dyscrasias who are at high risk with anticoagulants, the treatment of choice is an inferior vena cava filter. This device prevents migration of large clots into the pulmonary circulation, and complications associated with this device are rare. Thoracentesis is performed in the patient with pleural effusion to remove excess fluid accumulated in the pleural spaces. A patient with pleurisy is given intercostal nerve block to relieve chest pain. Pulmonary embolectomy has a high incidence of mortality but may benefit the patient who is hemodynamically unstable with massive pulmonary embolism. p. 529-531
A nurse is caring for a client who is post-op and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicated the client is experiencing respiratory acidosis? pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
