PREPU-Resp 1
A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which of the following complications should the nurse be prepared to treat? a) Pneumothorax b) Bronchopneumonia c) Clotted catheter d) Sepsis
a) Pneumothorax Explanation: Pneumothorax can occur from inadvertent puncture of the pleura, causing sudden chest pain and shortness of breath. Bronchopneumonia would not occur as a result of catheter contamination. Bronchopneumonia is an infection in the lung tissue. The central line is inserted in the venous system, namely the subclavian vein in this situation. The other answers are incorrect because they are not complications from central line insertions. The nurse must assess the client carefully for these complications to ensure that the parenteral nutrition is being administered safely.
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? a) Swallow reflex b) Medication allergies c) Presence of carotid pulse d) Ability to deep breathe
a) Swallow reflex Explanation: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.
The nurse is assessing a client recovering from anesthesia. Which is an early indicator of hypoxemia? a) somnolence b) restlessness c) urgency d) chills
b) restlessness Explanation: One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Limit the amount of protein in the diet." b) "Oral intake of fluids should be limited for 1 week only." c) "Clean the tracheostomy tube with alcohol and water." d) "Family members should continue to talk to the client"
d) "Family members should continue to talk to the client" Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing
An older adult has asthma and asks the nurse about taking the pneumonia vaccine. The nurse should tell the client: a) "You do not need the vaccine unless you are exposed to pneumonia." b) "You will need the vaccine only if you have frequent asthma attacks." c) "You should not have the vaccine because it is contraindicated in asthma." d) "You should receive the vaccine."
d) "You should receive the vaccine." Explanation: Elderly clients, especially those with existing respiratory compromise, are good candidates for the pneumonia vaccine. This vaccine provides immunity and prophylaxis against pneumococcal pneumonia or bacteremia in adults or children at risk. The nurse should encourage the client to take the vaccine. Taking the vaccine is not related to frequency of asthma attacks, and the vaccine is not contraindicated for clients with asthma.
Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?
Answer: Use sterile gloves during the procedure Explanation: The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not to be use on open wounds. The client should be in high Fowler's, not semi-Fowler's position.
Which finding would suggest pneumothorax in a trauma victim?
Answer: absent breath sounds Explanation: Pneumothorax means that there is air in the pleural space causing pressure on the lung and the lung will collapse. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs:
Answer: are not able to blow off carbon dioxide. Explanation: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, but the lungs' ability to remove carbon dioxide from the system is compromised. Although individuals with COPD frequently have a history of smoking, impaired ciliary function is not the cause of the acidosis.
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by the:
Answer: arterial blood gas values. Explanation: The client's ABG levels are the most sensitive indicator of the effectiveness of the client's oxygen therapy. Cyanosis is a late sign of decreased oxygenation and is not a reliable indicator. The client's respiratory rate and level of consciousness may be altered because of other problems not related to the client's oxygenation.
When instructing clients with allergic rhinitis about the use of nasal decongestants, it is important for the nurse to emphasize that:
Answer: continuous use for more than 3 days can result in worsening of symptoms. Explanation: The continuous use of nasal decongestants can result in a rebound effect when the agents are discontinued. This leads to a worsening of symptoms due to reflex vasodilation. Environmental changes can affect allergic rhinitis. The client should be instructed on identifying and avoiding exposure to allergens. Allergic rhinitis can occur during any season. It is not self-limited and may require prolonged management.
Arterial blood gas analysis would reveal which of the following related to acute respiratory failure?
Answer: pH 7.24 Explanation: Acute respiratory failure (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 a decreased arterial pH.
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?
Answer:A positive reaction indicates that the client has been exposed to the disease. Explanation: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.
The nurse is aware that the best position for a client with impaired gas exchange is what? You selected: High Fowler's Correct Explanation: For a client with impaired gas exchange, high Fowler's position is the best position because it allows maximal chest expansion. If the client cannot tolerate high Fowler's position, semi-Fowler's is the next best choice, because it increases comfort and allows for chest expansion. The lateral decubitus and supine positions do not promote chest expansion. Sims position is recommended for perineal inspectio
You selected: High Fowler's Explanation: For a client with impaired gas exchange, high Fowler's position is the best position because it allows maximal chest expansion. If the client cannot tolerate high Fowler's position, semi-Fowler's is the next best choice, because it increases comfort and allows for chest expansion. The lateral decubitus and supine positions do not promote chest expansion. Sims position is recommended for perineal inspection
The nurse has received a change of shift report on clients. Which client should the nurse assess first? a) a client with asthma with respirations of 36 breaths/min whose wheezing has diminished b) a client with asthma who has a heart rate of 90 bpm and whose beta blocker is scheduled to be administered now c) a client with COPD with a PaO2 of 56 mm hg who is being discharged home on oxygen d) a client who is scheduled for an angiogram now and is ready to be transported
a) a client with asthma with respirations of 36 breaths/min whose wheezing has diminished Explanation: Respirations of 36 breaths/min and diminished wheezing are indicative of respiratory distress. This finding takes precedence over a client scheduled for an angiogram, a client with a heart rate if 90 bpm needing a scheduled beta blocker, or a client with a PaO2 of 56 mm hg, which is indicated for a client being discharged home on oxygen.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which statement is true concerning oxygen administration to a client with COPD? a) Administration of oxygen is contraindicated in clients who are using bronchodilators. b) High oxygen concentrations may inhibit the hypoxic stimulus to breathe. c) High oxygen concentrations will cause coughing and dyspnea. d) Increased oxygen use will cause the client to become dependent on the oxygen.
b) High oxygen concentrations may inhibit the hypoxic stimulus to breathe. Explanation: Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) Stripping the chest tube every hour b) Measuring and documenting the drainage in the collection chamber c) Keeping the collection chamber at chest level d) Maintaining continuous bubbling in the water-seal chamber
b) Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? a) Position in orthopneic position and encourage the client to calm down. b) Position in high Fowler's position and administer an albuterol sulfate inhaler. c) Position in Fowler's position and administer oxygen. d) Position in a semi-prone position and encourage deep breathing.
b) Position in high Fowler's position and administer an albuterol sulfate inhaler. Explanation: Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing.
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis
b) Respiratory acidosis Explanation: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? a) The client is developing subcutaneous emphysema. b) The chest tube system is functioning properly. c) An obstruction is present in the chest tube. d) There is a leak in the chest tube system.
b) The chest tube system is functioning properly. Explanation: Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.
Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? a) The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula. b) The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. c) The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate. d) The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst.
b) The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Explanation: Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? a) hand hygeine b) airborne precautions c) droplet precautions d) contact precautions
b) airborne precautions Explanation: Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if recirculation is unavoidable. While hand hygiene is important, it is not sufficient to prevent transmission of tuberculosis.. Contact precautions are for clients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission.
An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? a) implementing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules b) applying an oximeter and initiating respiratory therapy c) inserting an IV line and initiating antibiotic therapy d) placing the client on bed rest and obtaining a prescription for a blood gas analysis
b) applying an oximeter and initiating respiratory therapy Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: a) "I should eat a high-protein diet." b) "I need to keep my inhaler at the bedside." c) "I should become involved in a weight loss program." d) "I should sleep on my side all night long."
c) "I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a) Prior outcomes of weaning b) Electrocardiogram (ECG) results c) Baseline arterial blood gas (ABG) levels d) Fluid intake for the past 24 hours
c) Baseline arterial blood gas (ABG) levels Explanation: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? a) respirations of 12 breaths/min b) oxygen saturation of 96% on room air c) arterial oxygen level of 46 mm Hg (6.1 kPa) d) lack of adventitious lung sounds
c) arterial oxygen level of 46 mm Hg (6.1 kPa) Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion? a) respirations unlabored b) hollow sound on chest percussion c) breath sounds clear on auscultation d) decreased mucus production
c) breath sounds clear on auscultation Explanation: Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a) pH, 7.29; PaCO2 30 mm Hg b) pH, 7.5; PaCO2 30 mm Hg c) pH, 7.25; PaCO2 50 mm Hg d) pH, 7.35; PaCO2 70 mm Hg
c) pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention? a) 45 mm Hg b) 60 mm Hg c) 35 mm Hg d) 80 mm Hg
d) 80 mm Hg Explanation: Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level. The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.
Which measure should the nurse perform when suctioning a tracheostomy tube? a) Change the tracheostomy tube after suctioning the client. b) Apply suction while inserting the suction catheter into the tube. c) Select a suction catheter that approximates the diameter of the tracheostomy tube. d) Administer high concentrations of oxygen before suctioning the client.
d) Administer high concentrations of oxygen before suctioning the client. Explanation: Clients are hyperoxygenated before suctioning to prevent hypoxia. Suction is never applied while inserting the catheter into the airway. Laryngectomy tubes are not changed after suctioning. The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure.
Which performance improvement strategy helps prevent adverse reactions to blood products? a) Priming the blood administration tubing with normal saline solution b) Instructing the client about the signs and symptoms of a blood reaction c) Obtaining baseline vital signs d) Confirming client identification with two qualified health professionals
d) Confirming client identification with two qualified health professionals Explanation: The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions
To more easily remove thick, tenacious secretions when suctioning a tracheostomy, the nurse should liquefy the secretions before suctioning by instilling the tracheostomy tube with 1 to 2 mL of sterile: a) a solution of 5% dextrose in water. b) bacteriostatic water. c) water. d) Normal saline normal saline solution.
d) Normal saline normal saline solution. Explanation: Sterile normal saline is the solution of choice for instillation into a tracheostomy tube cannula to help liquefy sticky secretions. Normal saline solution is less irritating to mucous membranes than plain water, bacteriostatic water, or a dextrose solution
The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition? a) Metabolic acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Respiratory acidosis
d) Respiratory acidosis Explanation: Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis and alkalosis are not directly caused by respiratory disorders.
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? a) Turn the client every 4 hours. b) Administer oxygen every 2 hours. c) Administer sedatives to promote rest. d) Suction if cough is ineffective.
d) Suction if cough is ineffective. Explanation: The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives to promote rest is contraindicated in acute respiratory distress because sedatives can depress respirations.
A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first? a) The client with anorexia, weight loss, and night sweats b) The client who had difficulty sleeping, daytime fatigue, and morning headache c) The client with crackles and fever who is complaining of pleuritic pain d) The client with unilateral leg swelling who's complaining of anxiety and shortness of breath
d) The client with unilateral leg swelling who's complaining of anxiety and shortness of breath Explanation: The client who is complaining of anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: a) place the client supine in the bed, which is flat. b) raise the arm on the side of the client's body on which the physician will perform the thoracentesis. c) raise the head of the bed to a high Fowler's position. d) assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
d) assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity
A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, the nurse should next: a) let the client rest, so the client is not stimulated to cough. b) encourage the client to take deep breaths to help control the pain. c) reassure the client that the machine is working and will administer medication to relieve the pain. d) obtain a more detailed assessment of the client's pain using a pain scale.
d) obtain a more detailed assessment of the client's pain using a pain scale. Explanation: Systematic pain assessment is necessary for adequate pain management in the postoperative client. Guidelines from a variety of health care agencies and nursing groups recommend that institutions adopt a pain assessment scale to assist in facilitating pain management. Even though the client is receiving morphine sulfate by PCA, and the pump is working, the nurse should continue to assess the client. The concern is not to eliminate coughing but to control pain adequately. Coughing is necessary to prevent postoperative atelectasis and pneumonia. Breathing exercises may help control pain in some circumstances; however, most clients with thoracic surgery require parenteral opioid analgesics in the early postoperative period. Although it is necessary that the PCA device be checked periodically, reassuring the client is not sufficient, so further assessment is needed.
A client with end-stage pulmonary hypertension tells the physician he doesn't want any heroic measures should his heart stop, and he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision?
-Autonomy Explanation: Autonomy is the client's right to make his own decisions. This client made the decision to have no heroic measures, so the nurse who supports this is upholding the principle known as autonomy. Nonmaleficence is the duty to "do no harm." Beneficence is characterized by doing good. Justice is equated with fairness
A home health nurse sees a client with end-stage chronic obstructive pulmonary disease (COPD). An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? a) Decreased oxygen requirements b) Increased sputum production c) Increased white blood cell count d) Decreased activity tolerance
a) Decreased oxygen requirements Explanation: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements. Elevated white blood cell count may be indicative of infection
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: a) moderate pain that worsens on inspiration. b) a mild but constant aching in the chest. c) severe midsternal pain. d) muscle spasm pain that accompanies coughing.
a) moderate pain that worsens on inspiration. Explanation: Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client: a) uses the sternocleidomastoid muscles. b) asks for an additional pillow. c) wants the head of the bed raised to a 90-degree level. d) has a pulse oximetry reading of 91%.
a) uses the sternocleidomastoid muscles. Explanation: Use of accessory muscles indicates worsening breathing conditions. Asking for an additional pillow, having a 91% pulse oximetry reading, and requesting the nurse to raise the head of the bed are not indications of a worsening condition
The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. The nurse should tell the client to: a) cough and deep-breathe before inhaling the medication. b) inhale quickly when administering the medication. c) rinse the mouth after each use of a steroid inhaler. d) inhale the medication and then exhale through the nose.
c) rinse the mouth after each use of a steroid inhaler. Explanation: Clients should be instructed to rinse their mouths after using a steroid inhaler to avoid developing thrush. Clients should also be instructed to inhale slowly through the mouth and then hold the breath as they count to 10 slowly. It is not necessary for the client to cough and deep-breathe before using the inhaler.
A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Draw blood for a hematocrit and hemoglobin level. b) Prepare a chest tube insertion tray. c) Prepare to start an I.V. line. d) Apply a dressing over the wound and tape it on three sides.
d) Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?
-Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered. Explanation: Priority actions are important to maximize effective ventilation because of the narrowing and spasms of the bronchioles and excessive secretions. It is important to position the client in the high Fowler's position and to oxygenate. The use of bronchodilators help counteract the bronchospasms. Other positions, such as supine and recovery, are not as effective as Fowler's. Ambulation increases the demand for oxygen, so is incorrect
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which findings is expected? a) coarse crackles and rhonchi b) normal breath sounds c) normal chest movement d) prolonged inspiration
a) coarse crackles and rhonchi Explanation: Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. The priority for care is first to: a) maintain adequate oxygenation. b) maintain adequate circulating volume. c) reduce the client's anxiety. d) decrease chest pain.
a) maintain adequate oxygenation. Explanation: Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is maintaining adequate circulatory volume
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? a) Institute isolation precautions. b) Obtain a sputum specimen for enzyme immunoassay testing. c) Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. d) Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing.
a) Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Tidal volume b) Maximal voluntary ventilation c) Functional residual capacity d) Vital capacity
A) Tidal Volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Answer: Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?
Answer: Maintain adequate oxygenation. Explanation: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.
The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
Answer: Sitting forward with the arms supported on the bedside table. Explanation: In preparation for a thoracentesis, the client should be asked to sit forward and place his arms on the bedside table for support. This position provides access to the chest wall and intercostal spaces for insertion of the needle. The supine, Sims', or prone position would not provide adequate access to the chest wall or separate the intercostal spaces sufficiently for needle insertion
The nurse is assessing a client with a right pneumothorax. Which assessment findings would be expected? a) Bilateral pleural friction rub. b) Tracheal shift to the right. c) Absence of breath sounds in the right thorax. d) Chest pain on inspiration. e) Inspiratory wheezes in the right thorax.
c) Absence of breath sounds in the right thorax. d) Chest pain on inspiration. Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. The tracheal will shift to the unaffected side. Commonly chest pain occurs on inspiration.
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? a) Developing a list of people with whom the client has had contact b) Reviewing the risk factors for TB c) Client teaching about the importance of TB testing d) Client teaching about the cause of TB
a)Developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.
10. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: a. Contralateral side in hemothorax b. Affected side in a hemothorax c. Affected side in a tension pneumothorax d. Contralateral side in a simple pneumothorax
a. Contralateral side in hemothorax Explanation: The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea won't shift. Tracheal deviation toward the contralateral side occurs in simple pneumothorax when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.
A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? a) "I should plan to do most of my exercises after I eat." b) "I should do my most difficult activities when I first get up in the morning." c) "I should try to eat several small meals during the day." d) "I should take my bronchodilator at bedtime to prevent insomnia."
c) "I should try to eat several small meals during the day." Explanation: The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals. Bronchodilators will increase insomnia. Activities should be regulated throughout the day. Eating followed by activity based on intra-abdominal pressure will increase shortness of breath.
The nurse is caring for a client with a tracheotomy. When suctioning the client, which actions would be considered safe nursing practice? Select all that apply. a) Oxygenate the client, then suction for 10 to 15 seconds while withdrawing the catheter. b) Suction every 4 hours when there are copious thick secretions. c) Commence suctioning upon insertion of the catheter and continue for 5 seconds while withdrawing the catheter. d) Insert the suction catheter as far as the client can tolerate and suction for 25 seconds. e) Suction when needed to prevent secretions from accumulating.
a) Oxygenate the client, then suction for 10 to 15 seconds while withdrawing the catheter. e) Suction when needed to prevent secretions from accumulating. Explanation: Prior to suctioning, the client should be oxygenated to increase blood oxygen saturation levels. During removal of the suction catheter, the nurse should suction between 10-15 seconds and then re-oxygenate the client. Suctioning is done only when needed, not as a routine measure. The suction catheter is inserted the just beyond the length of the tracheotomy tube and suction pressure is not applied during insertion of the catheter, only when withdrawing it.
A client with emphysema is at a greater risk for developing what acid-base imbalance? a) Respiratory alkalosis b) Chronic respiratory acidosis c) Metabolic alkalosis d) Chronic metabolic acidosis
b) Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Partial pressure of arterial oxygen (PaO2) c) Partial pressure of arterial carbon dioxide (PaCO2) d) Bicarbonate (HCO3-)
b) Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
The client is taking triamcinolone acetonide inhalant to treat bronchial asthma. The nurse should assess the client for: a) fluid retention. b) oral candidiasis. c) gastric ulcer. d) hyperglycemia.
b) oral candidiasis. Explanation: Acetonide inhalant is a corticosteroid. Use of a steroid inhaler can cause the client to develop oral candidiasis (thrush). It is important that the client rinse his or her mouth after using the inhaler. Acetonide inhalant does not lead to the development of systemic complications such as hyperglycemia, ulcers, or fluid retention.
A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate? a) A respiratory rate of 12 breaths/minute b) An oxygen saturation of 94% c) An inspiratory-expiratory (I:E) ratio of 2:1 d) A transverse chest diameter twice that of the anteroposterior diameter
c) An inspiratory-expiratory (I:E) ratio of 2:1 Explanation: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%
When caring for a client with a chest tube and water-seal drainage system, the nurse should: a) strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. b) verify that the air vent on the water-seal drainage system is capped when the suction is off. c) ensure that the chest tube is clamped when moving the client out of the bed. d) make sure that the drainage apparatus is always below the client's chest level.
d) make sure that the drainage apparatus is always below the client's chest level. Explanation: The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended
