Respiratory Disorders PassPoint
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:
inspiratory and expiratory wheezing. Explanation: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction.
The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client? "Do not take aspirin-containing medications for 2 weeks before surgery." "The results of the surgery will be immediately obvious postoperatively." "After surgery, nasal packing will be in place for 7 to 10 days." "Normal saline nose drops will need to be administered preoperatively."
"Do not take aspirin-containing medications for 2 weeks before surgery." Explanation: Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline nose drops are not routinely administered preoperatively. The results of the surgery will not be obvious immediately after surgery because of edema and ecchymosis.
A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter? 10 to 15 seconds 40 to 45 seconds 20 to 25 seconds 1 to 5 seconds
10 to 15 seconds Explanation: Suction should be applied for 10 to 15 seconds for each pass of the catheter. Suctioning for longer than 15 seconds removes oxygen from the respiratory tract and cause hypoxemia. Suctioning less than 10 seconds would not be adequate to remove the secretions.
When administering atropine sulfate preoperatively to a client scheduled for lung surgery, what should the nurse tell the client? "This medicine will reduce the risk of postoperative infection." "This medicine will help you relax." "This medicine will make you drowsy." "This medicine will make your mouth feel dry."
"This medicine will make your mouth feel dry." Explanation: Atropine is an anticholinergic drug that decreases mucus secretions in the respiratory tract and dries the mucus membranes of the mouth, nose, pharynx, and bronchi.
After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? 30 minutes 2.5 hours 4 hours 1 hour
30 minutes Explanation: Codeine's onset of action is 30 minutes. Its peak concentration occurs in about 1 hour; its half-life, in 2.5 hours; and its duration of action is 4 to 6 hours.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 2 to 4 months 3 to 5 days 6 to 12 months 1 to 3 weeks
6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the healthcare provider? subcutaneous emphysema at the insertion site continuous bubbling in the suction-control chamber intermittent bubbling in the water seal chamber 600 mL of blood in the collection chamber in 1 hour
600 mL of blood in the collection chamber in 1 hour Explanation: A blood loss of 600 mL may place the client in danger of developing hypovolemic shock. All of the other choices are normally expected with a chest tube.
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? Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Aspirational thoracentesis will be performed to remove the accumulated bloody fluid.
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax;
The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?
Acute respiratory distress syndrome (ARDS). Explanation: ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client's chances of recovery.
A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first? Auscultate the lung to determine whether it collapsed. Instruct the client to cough to expand the lung. Apply an occlusive dressing such as petroleum jelly gauze. Immerse the tube in sterile water.
Apply an occlusive dressing such as petroleum jelly gauze. Explanation: If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called. Placing the tube in sterile water will not reestablish a seal to prevent air entering the insertion site of the chest tube.
A nurse is caring for a client diagnosed with a deep vein thrombosis (DVT). The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 beats per minute, blood pressure of 100/60 mm Hg, and respirations of 40 breaths per minute. What is the nurse's priority action? Complete a neurological evaluation. Assess the client's oxygen saturation (SaO2) level. Order a 12-lead electrocardiogram. Document the findings and continue to monitor.
Assess the client's oxygen saturation (SaO2) level. Explanation: The client has symptoms consistent with a pulmonary embolism (PE). Assessment of airway and breathing and oxygenation status is the priority. Many clients begin treatment for PE on the basis of clinical history, symptoms, and clinical examination before definitive diagnostic testing has been completed.
A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which action by the nurse is most appropriate? Position the client in a low Fowler's position with the knees flexed. Assist the client to sit in a chair and lean slightly forward with hands on the knees. Place the client on bed rest. Place the client in the Trendelenburg position.
Assist the client to sit in a chair and lean slightly forward with hands on the knees. Explanation: Dyspnea is the primary disabling symptom of COPD and the most common. Persistent labored breathing is triggered by increased ventilation secondary to increased work of breathing. Dyspnea also has psychophysiological components, triggered by such factors as anxiety and fear causing clients to avoid exercise and abandon activities, leading to a downward spiral of disability. To help manage dyspnea, teach clients activities that reduce or control it such as sitting up in the "tripod" position where the client sits or stands leaning forward with the arms supported, forces the diaphragm down and forward, and stabilizes the chest while reducing the work of breathing. COPD clients require exercise; better exercise capacity decreases dyspnea and improves quality of life
A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do? Remove the packing if there is difficulty swallowing. Avoid rigorous aerobic exercise. Use 81 mg of aspirin daily for relief of discomfort. Omit the next dose of ramipril.
Avoid rigorous aerobic exercise. Explanation: Epistaxis, or nosebleed, is a common, sudden emergency. Commonly, no apparent explanation for the bleeding is known. With significant blood loss, systemic symptoms, such as vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur. Because aerobic exercise may increase blood pressure and increased blood pressure can cause epistaxis, the client with hypertension should avoid it.
Which health-promoting activity should the nurse teach the client who recently underwent a laryngectomy? Develop an aggressive program of exercise to increase airway functioning. Dehumidify the air for comfort. Avoid taking tub baths. Cleanse the mouth three times a day.
Cleanse the mouth three times a day. Explanation: Oral hygiene is an important aspect of self-care for the laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.
A nurse is caring for a client following an elective bronchoscopy. Which intervention by the nurse is most appropriate? Elevate the head of the bed to a high Fowler's position. Supply the client with ice chips to sooth a sore throat. Do not give the client anything by mouth until the gag reflex returns. Apply oxygen 2 L via nasal cannula for at least 4 hours after bronchoscopy.
Do not give the client anything by mouth until the gag reflex returns. Explanation: Assessing the risk for aspiration and maintaining an open airway is the priority. As a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the client to take oral fluids or food.
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? Administration of oxygen is contraindicated in clients who are using bronchodilators. High oxygen concentrations will cause coughing and dyspnea. Increased oxygen use will cause the client to become dependent on the oxygen. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
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.
A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next? Push code blue button calling for defibrillator call rapid response open the clients airway
Open the client's airway. Explanation: The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer ordered supplemental oxygen. Offer the client fluids frequently. Administer an ordered decongestant. Instruct the client to breathe into a paper bag.
Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
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, what should the nurse do next? Encourage the client to take deep breaths to help control the pain. Obtain a more detailed assessment of the client's pain using a pain scale. Let the client rest so the client is not stimulated to cough. Reassure the client that the machine is working and will administer medication to relieve the pain.
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.
A client has a chest tube attached to suction. Which interventions would the nurse perform? Select all that apply. 1. Mark the amount of drainage in the chamber at the end of the shift. 2. Palpate the surrounding area of the chest tube for crepitus. 3. Clamp the chest tube when suctioning the client. 4. Change the dressing as ordered using aseptic technique.
Palpate the surrounding area of the chest tube for crepitus. Mark the amount of drainage in the chamber at the end of the shift. Change the dressing as ordered using aseptic technique. Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated. This is referred to as crepitus or subcutaneous emphysema. Aseptic technique would be maintained when the dressing change was performed. At the end of each shift, the amount of drainage is marked on the chest tube container. The tubing is never clamped,
Following a thoracotomy, the client has pain of 9 on a 10-point scale. What should the nurse do thirty minutes after administering the highest dose of the prescribed pain medication? Reassure the client. Reposition the client. Reassess the client. Readjust the pain medication dosage as needed.
Reassess the client. Explanation: It is essential that the nurse evaluate the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of the pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client's pain, repositioning the client immediately after administering pain medication is not necessary. Verbally reassuring the client after administering pain medication may be useful to help instill confidence in the treatment plan; however, it is not as important as evaluating the effectiveness of the medication. Readjusting the pain medication dosage as needed according to the client's condition is essential, but the effectiveness of the medication must be evaluated first.
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?
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.
A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? 1. The employee does not remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room. 2. The employee removes all personal protective equipment and washes his/her hands before leaving the client's room. 3. The employee enters the room wearing a gown, gloves, and a mask. 4. The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room.
The employee enters the room wearing a gown, gloves, and a mask. Explanation: The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. Wearing a mask does not provide enough protection.
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 action should the nurse take? Call respiratory therapy for a breathing treatment. Encourage the use of the incentive spirometer. Use a sterile suction kit to suction the client. Teach the client pursed lip breathing.
Use a sterile suction kit to suction the client. Explanation: The priority for this client is suctioning to remove secretions in the upper airway if the client is unable to cough adequately. The other interventions will not effectively assist the client to maintain a patent airway.
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: have ineffective cilia from years of smoking. are unable to blow off carbon dioxide. are unable to inspire sufficient oxygen. are unable to exchange oxygen and carbon dioxide.
are unable 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 that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? pulmonary function test hemoglobin level red blood cell count arterial blood gases
arterial blood gases Explanation: Arterial blood levels include levels of oxygen in the body and determine the adequacy of alveolar gas exchange. Red blood cell count provides information on the quantity of red blood cells in the system.
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? arterial blood gases pulmonary function test hemoglobin level red blood cell count
arterial blood gases Explanation: Arterial blood levels include levels of oxygen in the body and determine the adequacy of alveolar gas exchange. Red blood cell count provides information on the quantity of red blood cells in the system. Pulmonary function tests measures lung volume and capacity. Although hemoglobin is the red pigment in the red blood cells that carries oxygen, it is not the best measurement of tissue oxygenation.
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should
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 comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease? amphotericin B rifampin azithromycin amantadine
azithromycin Explanation: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.
The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise? promote the intake of oxygen strengthen the diaphragm better elimination of carbon dioxide strengthen intercostal muscles
better elimination of carbon dioxide Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration
Which task may be safely delegated to a licensed practical nurse (LPN)? administering an I.V. bolus dose of morphine sulfate to a client experiencing incisional pain teaching a client newly diagnosed with diabetes mellitus about insulin administration changing the dressing of a client who underwent surgery 2 days ago admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit
changing the dressing of a client who underwent surgery 2 days ago Explanation: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.
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 Explanation: The clinical manifestations of a muffled voice and drooling suggest a possible peritonsillar abscess that could lead to an airway obstruction. This requires rapid assessment and potential treatment.
When instructing clients with allergic rhinitis about the use of nasal decongestants, it is important for the nurse to emphasize that:
continuous use for more than 3 days can result in worsening of symptoms. 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.
A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?
decreased hearing acuity Explanation: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be ordered
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? increased sputum production decreased oxygen requirements decreased activity tolerance increased white blood cell count
decreased oxygen requirements
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?
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.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: droplet nuclei forks, spoons dust
droplet nuclei. Explanation: Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air.
Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? high-calorie, high-protein diet low-sodium diet low-fat, low-cholesterol diet bland, soft diet
high-calorie, high-protein diet Explanation: The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated.
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider? green sputum laryngeal stridor hemoptysis dry cough
laryngeal stridor Explanation: Laryngeal stridor is characteristic of respiratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately. Green sputum indicates infection and would occur 3 to 5 days after bronchoscopy. A mild cough or hemoptysis is typical after bronchoscopy. If a tissue biopsy specimen was obtained, sputum may be blood-streaked for several days.
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately? low hemoglobin level normal erythrocyte sedimentation rate leukocytosis anemia
leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. This finding is expected in a client with rheumatic fever. Laboratory data indicating anemia or a low hemoglobin level will need to be addressed but are not critical and associated with the current disease process.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? tracheostomy cleaning kit manual resuscitation bag water-seal chest drainage set-up oxygen analyzer
manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary.
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of arterial blood gas values does the nurse expect for this client? pH 7.35, PaCO2 46, HCO3 30 pH 7.29 PaCO2 36, HCO3 19 pH 7.25, PaCO2 48, HCO3 24 pH 7.30, PaCO2 28, HCO3 16
pH 7.25, PaCO2 48, HCO3 24 Explanation: The nurse would expect a client with ARDS to exhibit respiratory acidosis. The results of pH 7.25, PaCO2 48, HCO3 24 indicate respiratory acidosis.
Clients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk? physical and emotional stress more exercise weather
physical and emotional stress Explanation: Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis.
A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?
pneumonia Explanation: Pneumonia is the most common complication of influenza. It may be either primary influenza, viral pneumonia, or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.
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 complication should the nurse be prepared to treat? pneumothorax sepsis bronchopneumonia clotted catheter
pneumothorax Explanation: Pneumothorax can occur from inadvertent puncture of the pleura, causing sudden chest pain and shortness of breath.
A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which action is the nurse's most appropriate action? preparing the client for an emergency thoracotomy preparing the client for a chest tube insertion preparing the client for a pericardiocentesis preparing the client for a tracheostomy
preparing the client for a chest tube insertion Explanation: The client's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube. The other options would not be appropriate actions.
The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the expected outcome of using pursed-lip breathing? relief from shortness of breath increased oxygenation prolonged exhalation increased exercise tolerance
prolonged exhalation Explanation: The primary reason for instructing the client with emphysema about how to pursed-lip breathe is to prolong exhalation. Prolonging exhalation helps to prevent bronchiolar collapse and the trapping of air. It does not increased exercise tolerance.
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: increased PaCO2. metabolic acidosis. acute CNS disturbances. respiratory alkalosis.
respiratory alkalosis. Explanation: Extreme anxiety can lead to hyperventilation, which is the most common cause of acute respiratory alkalosis. Hyperventilation may be a response to metabolic acidosis, as the body attempts to rid itself of excess CO2; hyperventilation does not cause metabolic acidosis.
A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply. orthopneic breathing exhibited use of accessory muscles with each breath oxygen saturation on room air is 95%. breath sounds present and equal in all lobes respiratory rate of 12 to 20 breaths per minute
respiratory rate of 12 to 20 breaths per minute breath sounds present and equal in all lobes oxygen saturation on room air is 95%. Explanation: A respiratory rate of 12 to 20 breaths/min is a normal finding, indicating adequate respiratory function. If the pneumothorax is not completely resolved, the client will not have breath sounds heard equally in the affected lobe(s). Normal oxygen saturation on room air is 95% to 100%. Orthopneic breathing and accessory muscle use indicate an interference with respiratory function.
The health care provider (HCP) has prescribed pseudoephedrine. The nurse should instruct the client about which possible adverse effect of this drug? constipation diplopia bradycardia restlessness
restlessness Explanation: Adverse effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS). The most common CNS adverse effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular adverse effects include tachycardia, hypertension, palpitations, and arrhythmias. Constipation and diplopia are not adverse effects of pseudoephedrine. Tachycardia, not bradycardia, is an adverse effect of pseudoephedrine.
While suctioning a client's laryngectomy tube, the nurse should insert the catheter: as the client exhales. until the client begins coughing. until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). about 1 to 2 inches (2.5 to 5 cm).
until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). Explanation: The proper suctioning technique is to insert the suction catheter until resistance is met (typically about 5 to 6 inches [13 to 15 cm]), withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm), then begin applying intermittent suction while withdrawing the catheter.It is not necessary to insert the catheter as the client exhales.
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: has a pulse oximetry reading of 91%. uses the sternocleidomastoid muscles. asks for an additional pillow. wants the head of the bed raised to a 90-degree level.
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.