Respiratory Disorders
A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?
Fighting the ventilator
A positive tuberculin skin test indicates that a client:
has produced an immune response.
After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:
meet the fluid and nutritional needs of the client.
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
"Family members should continue to talk to the client."
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?
"I should try to eat several small meals during the day."
Which family member exposed to tuberculosis would be at highest risk for contracting the disease?
76-year-old grandmother
What should be readily available at the bedside of a client with a chest tube in place?
A bottle of sterile water
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
Administer 100% oxygen by mask.
A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The client is able to ambulate. What should the nurse do?
Change the bed sheets frequently.
A client with emphysema is at a greater risk for developing what acid-base imbalance?
Chronic respiratory acidosis
A nurse is assigned to triage the care of four clients. Which client should the nurse assess first?
Client with a sore throat who now has a muffled voice and is drooling
A client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?
Intermittent suction while withdrawing the catheter
A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:
Nervousness.
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which sign or symptom should be included in the teaching plan?
Peripheral edema
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?
Position in high Fowler's position and administer an albuterol sulfate inhaler.
A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?
Pulmonary hypertension
Which information should the nurse include in a postoperative teaching plan for a client with a laryngectomy?
Reassure the client that normal eating will be possible after healing has occurred.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
Respiratory acidosis
As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance?
Respiratory acidosis
As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
Respiratory acidosis
The nurse teaches the client how to instill nose drops. Which technique is correct?
The client blows the nose gently before instilling drops.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat
A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which of the following actions should the nurse take?
Use a sterile suction kit to suction the client
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing
A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?
Vesicular
The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations. The nurse should do all except:
administer naloxone.
The nurse instructs the unlicensed assistive personnel (UAP) on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to:
mark the time and amount of drainage on the collection container.
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
While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first action should be to:
open the client's airway.
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?
pH, 7.25; PaCO2 50 mm Hg
An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is:
relax bronchial smooth muscle.
Which outcome criteria would the nurse develop for a child with cystic fibrosis who has ineffective airway clearance related to increased pulmonary secretions and inability to expectorate?
respiratory rate and rhythm within expected range
Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia?
the ability to perform activities of daily living without dyspnea
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects:
while exhaling through pursed lips.
Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)?
Maintaining functional ability
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
10 seconds
When caring for a client who has just had a total laryngectomy, the nurse should plan to:
Develop an alternative communication method.
A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for:
hearing loss.
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse?
4 hours
Which measure should the nurse perform when suctioning a tracheostomy tube?
Administer high concentrations of oxygen before suctioning the client.
After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema?
Apply cold compresses to the area.
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:
Are not able to blow off carbon dioxide.
A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next?
Assess the client for pain and medicate as appropriate.
An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals blood pressure (BP) 160/78, heart rate (HR) 102 beats per minute, and respiration rate 32 breaths per minute with audible wheezing. Which of the following is the nurse's priority action?
Assess the client's airway
A nurse is caring for a client with influenza who becomes agitated and restless. Which of the following is the priority nursing action?
Assess the client's lungs and check the oxygen saturation
The client is ready for discharge after surgery for a deviated septum. Which instruction would be appropriate?
Avoid activities that elicit Valsalva's maneuver.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings?
Increased anteroposterior chest diameter
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:
Ineffective airway clearance.
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:
Maintain adequate oxygenation.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should the nurse include in the plan of care?
Maintain the head of the bed at 30 to 40 degrees
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:
May induce bronchospasm
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?
Measuring and documenting the drainage in the collection chamber
After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?
Respiratory depression
The nurse is planning to assist the health care provider (HCP) with a thoracentesis for a client who has a pleural effusion. Which position would be appropriate for the client to assume?
Sitting upright and leaning on an overbed table
An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:
dyspnea
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and oxygen saturation every 15 to 30 minutes.
The nurse is preparing the client diagnosed with pleural effusion for a left-sided thoracentesis. The x-ray shows fluid in the pleural cavity. During the preparation for the procedure, the client asks where the health care provider (HCP) will "put the needle." Select the appropriate site from the diagram.
Place it in the second from the bottom not counting the floating ribs
The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?
Pneumonia
A nurse is caring for a client diagnosed with right-middle-lobe pneumonia at the last health care provider's appointment. The client has completed albuterol breathing treatments and a full dose of antibiotics. When assessing the client's lung fields, where would the nurse confirm improved air movement?
Put the "X" on the middle of the right middle lobe
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?
airborne precautions
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the healthcare provider (HCP)?
arterial oxygen level of 46 mm Hg (6.1 kPa)