Respiratory: PP-Pt. 1

Q: A client with bacterial pneumonia is to be started on IV antibiotics. Which diagnostic tests must be completed before antibiotic therapy begins? A: Sputum culture.

Rationale: A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Urinalysis, a chest radiograph, and a red blood cell count do not need to be obtained before initiation of antibiotic therapy for pneumonia.

Q: When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as: A: Cheyne-Stokes respirations.

Rationale: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.

Q: 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? A: Decreased hearing acuity

Rationale: 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. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.

Q: A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that: A: the chest tube system is functioning properly.

Rationale: Fluctuation of fluid with respirations in the water seal column 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 bubbling occurs in the water seal column.

Q: 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 high Fowler's position and administer an albuterol sulfate inhaler.

Rationale: 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.

Q: 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: Respiratory acidosis.

Rationale: 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.

Q: A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect? A: Irregular heartbeat

Rationale: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

Q: The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A: Keep the client oriented. Apply antiembolic stockings. Obtain vital signs.

Rationale: It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the UAP. The UAP can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with the health care provider's prescriptions. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.

Q: After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings: A: meet the fluid and nutritional needs of the client.

Rationale: The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client as the surgical site is healing. The feeding tube does help prevent aspiration by preventing ingested fluid from leaking through the wound into the trachea before healing occurs; however, the primary rationale is to meet the client's nutritional and fluid needs. A tracheoesophageal fistula is a rare complication of total laryngectomy and may occur if radiation therapy has compromised wound healing. A feeding tube does not help maintain an open airway.

Q: A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? A: Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24

Rationale: The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Option D indicates the early signs and symptoms of shock and the nurse should be most concerned.