Med surg: Respiratory Disorders ?S

apneic

Pertaining to the absence of breathing

A client has a respiratory rate of 4 breaths/min. What are this nurse's priority assessments? A. Arterial blood gas (ABG) and breath sounds B. Level of consciousness and a pulse oximetry value C. Breath sounds and reflexes D. Pulse oximetry value and heart sounds

Correct response: Level of consciousness and a pulse oximetry value Explanation: This nurse should first attempt to rouse the client to increase the respiratory rate. Pulse oximetry and breath sounds should be assessed, and the provider informed of the findings. An ABG analysis may be ordered to determine specific carbon dioxide and oxygen levels, which would indicate the effectiveness of ventilation. An assessment of reflexes and heart sounds would be part of the more extensive examination done after the respiratory rate has stabilized.

Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? Encourage the client to breathe shallowly. Have the client practice abdominal breathing. Offer the client incentive spirometry. Teach the client to splint the rib cage when coughing.

Correct response: Teach the client to splint the rib cage when coughing. Explanation: The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.

A client is diagnosed with a highly drug-resistant Klebsiella pneumonia. What priority information will the nurse include in the client's teaching plan? A. Washing hands before and after eating and as frequently as possible B. Having the house cleaned with bleach solution C. Completing antibiotics before discharge D. Wearing a mask when talking with other people

Correct response: Washing hands before and after eating and as frequently as possible Explanation: Clients should wash hands before and after they eat and as frequently as possible while hospitalized to reduce infections. Klebsiella is spread by person to person contact. The house does not need to cleaned with a bleach solution. The course of antibiotics may continue with discharge. There are no special precautions with a mask for the client because the bacteria does not spread through airborne means.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply. A. a client with bacterial meningitis B. an older adult client with influenza C. a client with a positive staphylococcus wound culture D. a client receiving antibiotics for a fever after surgery E. a client with a critically low white blood cell count

Correct response: a client with bacterial meningitis an older adult client with influenza Explanation: Droplet precautions are used for clients with bacterial meningitis and influenza. The client with a positive staphylococcus wound culture needs contact precautions. The client receiving antibiotics for a fever after surgery will not require precautions. The client with the low white blood cell count will need neutropenic precautions.

A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should A. administer pain medication and delay client activity. B. tell the client why lung expansion is important. C. arrange a care schedule that includes rest periods. D. teach the client how to use an incentive spirometer.

Correct response: administer pain medication and delay client activity. Explanation: Administering pain medication and delaying any activity until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and acts as a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort.

The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the health care provider when the client has which symptom? loud wheezing tenacious, thick sputum decreased breath sounds persistent cough

Correct response: decreased breath sounds Explanation: Diminished breath sounds during an acute asthma attack are a serious sign of airway obstruction, fatigue, and impending respiratory failure. Wheezing, coughing, and the production of sputum indicate the presence of airflow through the lungs and are less ominous symptoms.

The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: A. dust particles. B. droplet nuclei. C. water. D. eating utensils.

Correct response: droplet nuclei. Explanation: Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli. Tuberculosis is not spread by eating utensils, dishes, or other fomites.

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

Correct response: pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. B. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. C. The client exhibits restlessness and confusion. D.The client exhibits bronchial breath sounds over the affected area.

Correct response: A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

When assessing a client with asthma, which findings would most likely indicate the presence of a respiratory infection? A. cough productive of yellow sputum B. bilateral expiratory wheezing C. chest tightness D. respiratory rate of 30 breaths/min

Correct response: cough productive of yellow sputum Explanation: A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present.