Respiratory Disorders

A client is suspected of impending anaphylaxis secondary to hypersensitivity to a medication. What is the priority action by the nurse? Administer oxygen. Obtain a complete blood count (CBC). Insert an I.V. catheter. Take vital signs.

Administer oxygen

A nurse is caring for a client who has a tracheostomy and a temperature of 103° F (39.4° C). Which intervention, if implemented by the nurse, may most likely lower the client's arterial blood oxygen saturation? Use of cooling blanket Encouragement of coughing Incentive spirometry Endotracheal suctioning

Endotracheal suctioning

A client is receiving emergency care following a motor vehicle collision. The health care provider has diagnosed a left pneumothorax. Which sign would typically be present upon auscultation of the client's lungs? wheezing on expiration throughout the lung fields clear breath sounds bilaterally crackles one-third up the posterior lung fields absence of breath sounds over the left lung field

absence of breath sounds over the left lung field

A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first? bradycardia nonproductive cough distended jugular veins dyspnea

dyspnea

The parent of a 2-year-old child with epiglottitis states she has to leave to pick up another child from school. The 2-year-old child begins to cry with stridor. Which intervention by the nurse is best? Tell the 2-year-old everything will be all right. Tell the 2-year-old that the nurse will stay. Ask the parent if someone else can pick up the older child. Ask the parent how long she may be gone.

Ask the parent if someone else can pick up the older child.

A nurse monitoring a client with a chest tube connected to a water seal drainage device notices constant bubbling in the water seal chamber. What is the appropriate action by the nurse? Assess the chest tube connections and drainage device for an air leak. Check to make sure the suction is working correctly. Document the findings and continue to monitor. Notify the health care provider.

Assess the chest tube connections and drainage device for an air leak.

A nurse is caring for a client who underwent a total hip replacement. Which intervention should the nurse implement in this client's care to prevent dislocation of the new prosthesis? Use measures other than turning to reduce the possibility of pressure ulcers. Place several pillows under the knees to maintain hip flexed. Avoid moving the extremity into positions that cause internal rotation. Explain that the client's advance directive appoints the physician as the power of attorney for health care decisions.

Avoid moving the extremity into positions that cause internal rotation.

An unconscious, intoxicated client who took an overdose of an opioid receives naloxone to reverse the effect of the opioid. After the client awakens, what is the priority action by the nurse? Feed the client. Discharge the client from the hospital. Educate the client on the effects of taking pills and alcohol together. Admit the client to a psychiatric facility.

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells.

A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client? Instruct the client about the importance of TB testing. Discuss the cause of TB with the client's family members. Identify other people with whom the client had contact. Review the risk factors for TB with the client.

Identify other people with whom the client had contact.

For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? Teaching the client how to perform controlled coughing Administering prescribed sedatives regularly and in large amounts Restricting fluid intake to 1,000 ml/day Enforcing absolute bed rest

Teaching the client how to perform controlled coughing

The client who was diagnosed with pneumonia 2 days prior comes to the emergency department with a sudden onset of severe shortness of breath. The chest x-ray shows fluid in the alveolar spaces. Which disease should the nurse suspect this client to have? bronchitis TB asthma acute respiratory distress syndrome (ARDS)

acute respiratory distress syndrome (ARDS)

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: renal failure. bronchial asthma. adult respiratory distress syndrome (ARDS). chronic obstructive pulmonary disease (COPD).

adult respiratory distress syndrome (ARDS).

A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that they don't want to be resuscitated. The nurse should not provide any care. call the physician. get the crash cart. check the client's oxygen saturation.

check the client's oxygen saturation.

The nurse is reinforcing education with a client diagnosed with lung cancer. Which should the nurse include as most important to help increase survival rate of lung cancer clients? smoking cessation increased protein early bronchoscopy early detection

early detection

A nurse reinforce teaches a group of police officers about the spread of TB. Which statement by an officer indicates that teaching has been effective? "I could get TB by being in close proximity for a brief time with someone who has the disease." "I could get TB if I search the home of someone infected with TB." "I could get TB if I inhale infected droplets when an infected individual coughs." "I could get TB if I come in contact with blood from an infected person."

"I could get TB if I inhale infected droplets when an infected individual coughs."

On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse observes that the client is receiving oxygen at 4 L/minute by way of a nasal cannula. The nurse's next action should be based on which statement? "The flow rate is correct." "The flow rate is too high." "The client shouldn't receive oxygen." "The flow rate is too low."

"The flow rate is too high."

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? Keeping the collection chamber at chest level Stripping the chest tube every hour Maintaining continuous bubbling in the water-seal chamber Measuring and documenting the drainage in the collection chamber

Measuring and documenting the drainage in the collection chamber

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which data collection finding indicates that the client has developed the most serious complication of epidural analgesia? Numbness and tingling of the extremities Respiratory depression Heightened alertness Increased heart rate

Respiratory depression

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. When reviewing the client's chart, which term will the nurse find that refers to the volume of air inhaled or exhaled during each respiratory cycle? Tidal volume Vital capacity Functional residual capacity Maximal voluntary ventilation

Tidal volume

The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply. Have all people in contact with the client outside of the client's room wear a mask. Keep the client in strict isolation. Wear a face mask at all times. Wear gloves when handling tissues containing sputum. Keep the client's door open to allow fresh air into the room and to prevent social isolation. Wash hands after direct contact with the client or contaminated articles.

Wear gloves when handling tissues containing sputum. Wear a face mask at all times. Wash hands after direct contact with the client or contaminated articles.

A nurse working in a walk-in clinic has been alerted that there's an outbreak of tuberculosis (TB). Which client does the nurse identify as having the highest risk for developing TB? a 33-year-old day care worker a 43-year-old homeless man with a history of alcoholism a 16-year-old female high school student a 54-year-old businessman

a 43-year-old homeless man with a history of alcoholism

A nurse is assisting with the care of four clients. Which client requires the nurse to contact the primary health care provider? a client with a pleural effusion who has stabbing chest pain a client with emphysema scheduled to begin pulmonary rehabilitation a client with right-sided heart failure who has 2+ bilateral edema in the legs and feet a client experiencing tracheal deviation following a subclavian catheter insertion

a client experiencing tracheal deviation following a subclavian catheter insertion

The nurse is caring for a group of clients. Which client should be most closely monitored for the development of respiratory failure? a client with a fractured hip a client with cervical sprains a client with Guillain-Barré syndrome a client with breast cancer

a client with Guillain-Barré syndrome

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 who has an order for acetaminophen with codeine for pain but has not requested it a client with a history of smoking two packs of cigarettes per day until quitting 2 years ago a client who ambulates in the hallway daily a client with a nasogastric tube

a client with a nasogastric tube

A client arrives in the emergency department displaying apnea, altered mental status, and dyspnea and central cyanosis. The client was found inside a car by neighbors while the motor was still running. Which sign or symptom would the nurse expect to observe and is indicative of late-stage carbon monoxide poisoning? increased breath sounds cherry-red mucous membranes chest pains dilated pupils

cherry-red mucous membranes

The nurse auscultates inspiratory and expiratory wheezes with a decreased forced expiratory volume in a client with asthma. Which class of medication would the nurse expect to administer immediately? oral steroids bronchodilators beta blockers inhaled steroids

bronchodilators

The nurse is caring for a child with increased laryngotracheal edema and early signs of impending airways obstruction. The nurse should observe for which warning sign? increased temperature increased heart and respiratory rates, retractions, and restlessness decreased blood pressure decreased heart and respiratory rates and a high peak flow rate

increased heart and respiratory rates, retractions, and restlessness

The nurse is gathering data to determine the status of a client with a respiratory rate of 4 breaths/minute. What additional data should the nurse obtain? arterial blood gas (ABG) levels and breath sounds pulse oximetry value and heart sounds level of consciousness (LOC) and a pulse oximetry value breath sounds and reflexes

level of consciousness (LOC) and a pulse oximetry value

A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which physical finding would lead the nurse to believe it's appropriate to discharge this client? continued dyspnea respiratory rate of 32 breaths/minute fever of 102º F (38.9º C) normal vesicular breath sounds in right base

normal vesicular breath sounds in right base

A client requires a chest tube to be inserted in the right upper chest. Which action is part of the nurse's role? inserting the chest tube injecting local anesthetic to prevent pain bringing the chest x-ray to the client's room preparing the chest tube drainage system

preparing the chest tube drainage system

A client is admitted to the hospital with a diagnosis of respiratory failure. The client is intubated, placed on 100% FiO2, and is coughing up copious secretions. Which intervention has priority? suctioning the client obtaining an arterial blood gas (ABG) analysis getting an x-ray restraining the client

suctioning the client

A client is diagnosed with active tuberculosis (TB). What explanation does the nurse give to the client for being hospitalized? to determine his compliance to determine the need for antibiotic therapy to prevent spread of the disease to evaluate his condition

to prevent spread of the disease

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse would administer: protamine sulfate. vitamin K (phytonadione). vitamin C. heparin.

vitamin K (phytonadione).