n172 respiratory
After the nurse has taught a client with asthma about use of a peak flow meter, which client statements indicate that the teaching has been effective?
"Readings in the green zone mean that my asthma is under control.""If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital.""I should check the peak flow readings at least twice a day until my baseline is established."
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take?
Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula.
A client is hospitalized with a left pneumothorax, and when assessing the left chest area, the nurse would expect to identify which finding?
absence of breath sounds on auscultation
When a client is seen in the emergency department with sudden onset severe dyspnea, coughing, and wheezes, which prescribed treatment would the nurse administer first?
albuterol via nebulizer
When the nurse is reviewing a client's arterial blood gas results, which finding would the nurse identify as being consistent with respiratory alkalosis?
an elevated pH, decreased PCO2
Which nursing action would the nurse classify as the highest priority when a client's chest tube has accidentally dislodged?
apply a petroleum gauze dressing over the site
Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%?
arterial blood gas
After head and neck surgery for cancer, the client reports that the neck dressing is tight. Which action would the nurse take?
assess for signs of constriction
The nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. Which etiology is the probable cause of the severe dyspnea?
bronchial obstruction or pleural effusion
Which client activity warrants the highest priority for education about health promotion to prevent head and neck cancer?
chews tobacco, multiple sex partners, history of alcohol abuse for 5 years
Which arterial blood gas (ABG) value would indicate diabetic ketoacidosis?
decreased HCO3
Which assessment finding indicates to the nurse that a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen is retaining carbon dioxide (CO 2)?
drowsiness, irregular pulse, mental confusion
Which finding would best indicate to the nurse that the chest tube for a client with a pneumothorax may be discontinued?
full re-expansion of the lungs seen on chest xray
After a spontaneous pneumothorax, a client's assessment findings include extreme drowsiness, tachycardia, and tachypnea. Which condition would the nurse suspect?
hypercapnia
Which action would the nurse include in the plan for care of a client on the first postoperative day after a radical neck dissection for laryngeal cancer?
keep the client in semi-fowlers position when in bed (do not manipulate nasogastric tube, suctioning may be needing in mouth or trach, arm and shoulder used should be utilized to promote max return of function)
The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give?
keeps the airway open longer to decrease the work that goes into breathing
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse?
markedly decreased breath sounds
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance would the nurse identify based on these results?
metabolic acidosis
What are Kussmaul respirations indicative of?
metabolic acidosis
A client is hospitalized after 4 days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, pCO 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmolL), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). Which condition does the nurse determine the results indicate?
metabolic alkalosis
Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks?
mold, cold air, pet dander, air pollution, cigarette smoke
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO 289 mm Hg, PCO 2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition?
normal acid-base balance
Which finding requires the most rapid action when the nurse is assessing a client with laryngeal cancer who has had radical neck surgery?
rapid oozing of blood at neck incision
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?
respiratory acidosis
Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?
respiratory alkalosis
For a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted, which primary purpose of the chest tube will the nurse consider when planning care?
restores negative pressure in the pleural space
Which clinical indicator would the nurse expect to identify when assessing an individual with a spontaneous pneumothorax?
shortness of breathe, unilateral chest pain
A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately?
suction the tracheostomy
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care?
the tracheostomy tube interferes with effective coughing
Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough?
type of employment, presence of ear pain, history of tobacco use, oral hygiene practices, amount of alcohol intake
Which actions will the nurse include when doing tracheostomy care?
use sterile technique when cleaning the inner cannula, don sterile gloves before removing the inner cannula (a brush is used to clean the inner cannula NOT sterile cotton tipped swabs)
Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place?
check the water seal chamber for air bubbling, assist the client to cough and feel breathe every hour while awake (patients are okay to have NSAIDS as they help with chest tube pain, for a pneumothorax there would be minimal drainage in the collection chamber)
When a client with chronic obstructive pulmonary disease (COPD) reports a 5-1b (2.3-kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication?
cor pulmonale
A client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3 L/min nasal cannula. Four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. Which intervention would the nurse implement at this time?
discontinue or decrease the oxygen flow rate
Which assessment findings would indicate a possible asthma exacerbation?
wheezing, tachycardia
Which actions will the nurse take when caring for a client with possible lung cancer who has just had a thoracentesis?
listen to breath sounds, encourage deep breaths, send pleural fluid to the lab, ensure that a chest xray is performed
The nurse is developing a plan of care for a client who underwent extensive oral surgery for head and neck cancer. Which interventions would the nurse include in the plan to prevent infection?
protect incision site, remove thick secretions, provide oral care atleast every 4 hours
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on which likely cause of the spontaneous pneumothorax?
rupture of a subpleural bleb
A child is prescribed fluticasone after an acute asthma attack. Which instruction would the nurse give the family about the administration of this medication?
watch for white patches in the mouth and report to the health care provider (thrush)
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?
respiratory acidosis (expecting partial pressure of carbon dioxide (PCO2) is 40mmHg)
