N150 PrepU Ch. 8 & 9

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?

Sitting on the edge of the bed

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx?

Sore throat

A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?

"I will feel warm and may have chest pain"

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?

"It's very important that you remain still while the doctor is performing the procedure."

A 64-year-old patient and his wife have presented to their primary care provider. The patient's wife has prompted her husband to seek care because she is worried about his apneic episodes and loud snoring. The husband had earlier undergone a diagnostic workup for obstructive sleep apnea (OSA) and been diagnosed with the disease but is not motivated to treat his health problem. How can the nurse at the clinic best characterize the risks of OSA?

"Sleep apnea actually increases your risk of having a stroke or heart attack."

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy?

A client requires permanent ventilation.

The nurse is providing care for a number of patients who are receiving treatment for health problems that have a respiratory etiology. Which of the following patients is most likely to benefit from the administration of a PO or IV diuretic?

A patient who has crackles on auscultation

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A permanent tracheal stoma would be necessary.

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

Administering a cough suppressant as needed

The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?

Affected voice sounds

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

Amoxicillin-clavulanic acid

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

An antiviral agent such as acyclovir

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

Apply direct continuous pressure.

The nurse is mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

Aspiration Infection Injury to the laryngeal nerve

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?

Asthma

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

Which is a deformity of the chest that occurs as a result of overinflation of the lungs?

Barrel chest

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to

Blow the nose before applying medication into the nares.

The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?

CPAP prevents the collapse of the patient's airway

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP)

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform?

Count the rate of respirations.

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

Edema of the upper airway

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

Hypercapnia

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

Cyanosis

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in?

Decreased diffusion capacity for oxygen

After remaining in bed for 48 hours after surgery and dismissing nurses' encouragements to mobilize, a patient has begun to display the characteristic signs and symptoms of atelectasis. Because atelectasis is a health problem associated with decreased lung compliance, the nurse should understand that this patient is experiencing what pathophysiological phenomenon?

Decreased expandability of the patient's lung tissue

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.

Diaphragm contracts and elongates the chest cavity.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

Difficulty in breathing

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Do not eat or drink for 6 hours before the procedure.

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?

Dull

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Emphysema

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

Ensure mouth breathing

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

Epistaxis

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

Frontal

A nurse is receiving change-of-shift report about an older adult patient who has a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse's colleague reports that she has applied oxygen at 6 L/min by nasal prongs in an effort to bring the patient's oxygen saturation levels above 92%. How should the nurse best interpret this colleague's action?

Giving oxygen at a high rate has the potential to interfere with the patient's hypoxic drive.

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

Hoarseness of more than 2 week's duration

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

What would the instructor tell the students purulent fluid indicates?

Infection

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?

MRI can view soft tissues and can help stage cancers.

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours

A patient with a diagnosis of acute rhinosinusitis has approached the nurse and asked for advice about "rinsing out my sinuses with saltwater," a treatment that was suggested by a friend. The nurse's response should be premised on which of the following statements?

Nasal saline lavage can help to improve the patency of the sinuses.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.

On the cheeks below the eyes

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.

Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

Partial laryngectomy

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Pleurisy

The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply.

Polycythemia Loud snoring Insomnia

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress

During a period of significant workplace stress, a patient has been experiencing the recurrence of viral rhinitis for the past several weeks and claims that he has been unable to fully recover from this cold. The nurse should recognize that this patient is at risk of developing:

Rhinosinusitis

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?

Rhonchi

A 6-year-old girl has been admitted to the neurological ICU after suffering a brain injury that resulted from choking on a toy ball. This girl's injuries are ultimately a result of which of the following alterations in normal respiratory function?

Shunting

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

Stands behind the worker, who has hands across the neck

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

For which reason does gas exchange decrease in older adults?

The alveolar walls contain fewer capillaries.

The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

The cough reflex is depressed.

An emergency department (ED) nurse is caring for a patient complaining of dyspnea. The nurse assesses the patient's chest and hears wheezing throughout the lung fields. What might this indicate?

The patient is in bronchospasm.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

The pons

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

They can be heard during inspiration and expiration.

A 23-year-old man has missed numerous work days over the past 2 years as a result of chronic viral pharyngitis. The nurse who is providing care for this patient should recognize that this patient may benefit from:

Tonsillectomy

An acutely ill patient is in a supine position. What approach should the nurse take to assess the patient's lung fields for a patient in this position?

Turn the patient on his or her side to assess all lung fields, so that dependent areas can be assessed for breath sounds.

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

Type II

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?

Ventilation exceeds perfusion.

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract.

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume cycled

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

When the patient has less than 30 mL for 2 consecutive days

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

A nurse is examining a client's chest. During the exam, the nurse palpates what feels like bubbles under the client's chest muscles. Which term would the nurse use when documenting this finding?

crepitus

A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?

eustachian tubes

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include

hoarseness

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:

is breathing air in and out of the lungs.

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

laryngeal cancer

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

lungs

A Black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes.

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

pleural friction rub.

Pink, frothy sputum may be an indication of

pulmonary edema

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

"The ET tube will maintain your airway while you're under anesthesia."

Computed tomography of a patient's chest is suggestive of a malignancy, but these results are not conclusive. As a result, the patient has been scheduled for a bronchoscopy. What patient education should the nurse provide for this patient regarding this diagnostic procedure?

"We'll monitor you closely after the procedure, especially until your gag reflex returns."

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

20 mL or less

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

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