Med. Surg- Respiratory

The client diagnosed with sinusitis who has undergone a Caldwell Luc procedure is complaining of pain. Which intervention should the nurse implement first?

Assess the client's pain.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?

Assess the respiratory status and pulse oximeter reading

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?

Assist the client into a sitting position at 90 degrees.

Which instruction is most important for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital?

Avoid smoking and exposure to smoke.

The client has been diagnosed with chronic sinusitis. Which signs and symptoms would alert the nurse to a potentially life-threatening complication?

Nuchal rigidity.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?

Obtain a signed informed consent form.

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?

Obtain a sputum specimen for culture and sensitivity

The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse?

The client's pulse oximeter reading is 90%.

The nurse is caring for the client diagnosed with end-stage COPD. Which data would warrant immediate intervention by the nurse?

The client's sputum is rusty colored.

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?

The injury allows air into the pleural space but prevents it from escaping from the pleural space.

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.

-Place the client on oxygen by nasal cannula. -Plan for periods of rest during activities of daily living. -Monitor the client's pulse oximetry readings every four (4) hours

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS?

A synthetic surfactant.

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply.

-Assess the client's level of consciousness. -Turn the client every two (2) hours. -Maintain intravenous fluids as ordered. -Place the client in the Fowler's position.

Which nursing diagnoses would be appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply.

-Impaired gas exchange. -Inability to tolerate temperature extremes. -Activity intolerance. -Inability to cope with changes in roles.

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?

Assess skin color and temperature.

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply

-Keep protamine sulfate readily available -Assess for overt and covert signs of bleeding. -Avoid invasive procedures and injections. -Administer stool softeners as ordered.

The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply.

-Nursing -Pharmacy -Social Work

The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse that he has been blowing his nose frequently. Which question should the nurse ask the client?

"Are you taking over-the-counter medicine for these symptoms?"

The 56-year-old client diagnosed with tuberculosis (TB) is being discharged. Which statement made by the client indicates an understanding of the discharge?

"I must stay on the medication for months if I am to get well."

What statement made by the client would indicate that the nurse's discharge teaching was effective for the client diagnosed with COPD?

"I need to get an influenza vaccine each year, even when there is a shortage."

What statement made by the client diagnosed with chronic bronchitis indicates to the nurse that more teaching is needed?

"I need to return to the HCP to have my blood drawn with my annual physical."

The nurse is discharging a client newly diagnosed with restrictive airway disease,asthma. Which statement indicates the client understands the discharge instructions?

"I will call 911 if my medications don't control an attack."

Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective?

"I will wear a medic alert band at all times."

The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates that more teaching is needed?

"It doesn't matter if I smoke now. I already have cancer."

The nurse knows the client understands teaching regarding mast cell stabilizer medications when the client makes which statement?

"These drugs are not good at the time of an attack."

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near drowning. The client asks the nurse, "What is happening to me? Why did I get this?

"Your lungs are filling up with fluid, causing breathing problems."

The nurse writes a problem of "impaired gas exchange" for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply.

-Apply O2 via nasal cannula. -Have the dietitian plan for six (6) small meals per day. -Assess vital signs for fever. -Listen to lung sounds every shift.

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax.Which interventions should the nurse implement when caring for this client? Select all that apply.

-Assess chest tube drainage system frequently. -Secure a loop of drainage tubing to the sheet. -Observe the site for subcutaneous emphysema.

The registered nurse and a licensed practical nurse are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the licensed practical nurse?Select all that apply.

-The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1000 mL. -The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. -The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of95% and wants to sleep all the time.

The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.

-The client should wear a protective covering over the stoma when showering. -The client should use a humidifier in the room. -The client can get a special telephone for communication.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation(tidaling) in the water compartment?

Assess the client's bilateral lung sounds.

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement?

Administer the medication as ordered.

The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement?

Airborne Precautions.

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which would be an expected outcome for this problem?

Alert and oriented to person, place, time, and events.

Which action should the nurse implement for the client with a hemothorax who has aright-sided chest tube and there is excessive bubbling in the water-seal compartment?

Check the amount of wall suction being applied.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates that there is an increase in the peak airway pressure. Which intervention should the nurse implement first?

Check the tubing for any kinks.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax.Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment?

Check the tubing for kinks or clots.

When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse expect?

Chronic sputum production

The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation room and leaving the door open. Which action would be the nurse's best response?

Close the door and discuss the NA's action when the NA comes out of the room.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms would the nurse expect to find when assessing the client?

Confusion and lethargy

The health-care provider ordered stat arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24.Which action should the nurse implement?

Continue to monitor the client without taking any action.

What causes the "crackling" sounds in the lungs?

Crackles are caused by the "popping open" of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.

The unlicensed nursing assistant (NA) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?

Demonstrate the correct technique for giving a bed bath.

The practical nurse is working at a primary school and is presenting information to students on how to present the spread of the common cold virus. Which topics should the practical nurse discuss.

Demonstrate to students how to wash hands correctly

The nurse is completing the admission assessment on a 13-year-old client diagnosed with asthma. Which signs and symptoms would the nurse expect to find?

Dyspnea and wheezing.

The Influenza vaccine is in short supply. Which group of patients would the practical nurse consider priority when administering the vaccine?

Elderly and chronically ill patients.

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care?

Ensure that the ET tube is secure.

The nurse is admitting a client with a diagnosis of rule out cancer of the larynx. Which information should the nurse teach?

Explain that a lighted instrument will be placed in the throat to biopsy the area.

The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention would have priority?

Find out if the client can read and write

The client diagnosed with oat cell carcinoma of the lung tells the nurse, "I am so tired of all this. I might as well just end it all." Which should be the nurse's first response?

Find out if the client has a plan to carry out suicide.

The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering?

Hanging the heparin bag to a client with a PT/PTT of 12.9/98.

The client diagnosed with restrictive airway disease, asthma, has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?

Immediately rinse the mouth following administration of the drug.

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client?

Increase fluid intake to two (2) to three (3) liters a day.

The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement?

Institute and maintain bed rest.

Which information should the nurse teach the client diagnosed with acute sinusitis?

Instruct the client to complete all the ordered antibiotics.

The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach?

Investigational treatments have not been proved helpful to clients.

Why is 90 to 92 percent an acceptable oxygen saturation level in a person with chronic respiratory issues?

It is high enough to prevent acute dyspnea but not so high as to reduce respiratory drive.

The nurse is reviewing a patient's pulmonary function tests. Which of the following best describes functional residual capacity?

It is the air remaining in the lungs after normal expiration.

The physician orders local application of phenylephrine solution to treat a nosebleed. The patient asks how this will help. Which of the following responses by the nurse is best?

It will constrict your vessels and slow down the bleeding.

The patient returns to the medical unit after a pulmonary angiography. Which instructions by the nurse would help prevent complications from the test?

Lie flat for 8 hours so the injection site does not bleed.

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS?

Low arterial oxygen when administering high concentration of oxygen.

The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate?

Lung cancer is the number-one cause of cancer deaths in both men and women.

Which intervention should the nurse implement for a male client who has had a left sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much?

Medicate the client and have the client take deep breaths.

Is a sign/symptom of meningitis,which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges.

Nuchal rigidity

When assessing the client with the diagnosis of COPD, which data would require the nurse to take immediate action?

Oxygen flow meter set on eight (8) liters.

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first?

Place the client in a high Fowler's position

The primary nurse observes the unlicensed nursing assistant removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the primary nurse take?

Place the oxygen back on the client while sitting in the bathroom and say nothing.

The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis?

Plasma D-dimer test.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms would the nurse look for when assessing the client?

Pleuritic chest discomfort and anxiety.

When assessing the client with COPD, which health promotion information would be most important for the nurse to obtain?

Possibility for lifestyle changes.

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement?

Provide the client with a blank note pad for writing any communication.

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client?

Pulmonary function test

The nurse obtained a noninvasive measurement of the patient's oxygen saturation. What is this test called?

Pulse oximetry

An LVN enters the room of a patient with chronic lung disease. The patient has removed the oxygen cannula but does not appear to be in any distress. The pulse oximeter shows an oxygen saturation of 79%. Which of the following actions should the nurse take?

Put the oxygen cannula back on the patient

The nurse is discussing the care of a child diagnosed with asthma with the parent.Which referral would be important to include?

Referral for allergy testing.

The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. For which prophylactic procedure will the nurse prepare the client?

Removal of the teeth.

The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem would have the highest priority?

Respiratory distress.

What did the respiratory assessment include?

Respiratory rate, lung sounds, cough, skin color, oxygen saturation, accessory muscle use

A 17 year old student enters the emergency department with a nosebleed that won't stop. Which of the following positions should the nurse assist the patient to assume?

Sitting up leaning slightly forward

The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client?

Soft, regular diet.

The nurse is planning the care of a client diagnosed with asthma and has written a problem of "anxiety." Which nursing intervention should be implemented?

Stay with the client.

Which assessment data would support that the client has experienced a pulmonary embolus?

Sudden onset of chest pain and dyspnea.

The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first?

Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site

The charge nurse is making rounds. Which client should the nurse assess first?

The 29-year-old client diagnosed with reactive airway disease who is complaining that the nurse caring for him was rude.

The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first?

The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%.

The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?

The HCP can do a biopsy of the tumor through the scope.

The patient diagnosed with Influenza A is being discharged from the Emergency Department with a prescription for antibiotics. Which statement by the patient indicates understanding of this prescription?

The antibiotics will help me from developing a bacterial pneumonia.

While the nurse is caring for the client diagnosed with COPD, which outcome would require a revision in the plan of care?

The client demonstrates intolerance to activity

Which outcome would be appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD?

The client demonstrates the correct way to purse-lip breathe.

The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?

The client has 450 mL of bright-red drainage in the chest tube

The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?

The client has a towel placed over the mirror.

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which information should the practical nurse report to the registered nurse prior to surgery?

The client has an oral temperature of 100.2˚F and a dry cough

Which assessment data would indicate the client diagnosed with ARDS has experienced a complication secondary to the ventilator?

The client has asymmetrical chest expansion.

The nurse working in an outpatient clinic is interviewing clients. Which information provided by the client warrants further investigation?

The client has been coughing up blood in the mornings.

The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?

The client has smoked two (2) packs of cigarettes a day for 20 years.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN?

The client who is two (2) hours post-bronchoscopy procedure

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indicates the need for radiological evaluation instead of skin testing?

The client's previous skin test was read as positive.

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?

The nursing assistant has the chest tube attached to suction.

How should the LVN record smoking history on a patient who has smoked 2 packs of cigarettes per day for 20 years?

The patient has a 40 pack-year smoking history.

The client diagnosed with cancer of the larynx has had four (4) weeks of radiation therapy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain?

The treatments are also affecting the esophagus, causing ulcerations

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube?

There is no fluctuation (tidaling) in the water-seal compartment.

While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first?

Turn the client to the side.

The client is admitted to the emergency department with chest trauma. When assessing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax?

Unequal lung expansion and dyspnea.

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?

Use of a "rescue inhaler."

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching?

Use the bronchodilator inhaler immediately prior to beginning to exercise.

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?

Ventilate with a manual resuscitation bag.

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?

Vitamin C, 2000 mg daily.