Unit 7: Respiratory

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?

Open the client's airway. 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. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene?

A surgical face mask is applied before entering the client's room. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform.

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Impaired gas exchange Impaired gas exchange should be the nurse's first priority because of the lack of ventilation due to the surgical procedure and pain. The other options as not first priorities.

Which instruction should the nurse give the client who has undergone chest surgery to prevent shoulder ankylosis?

Raise the arm on the affected side over the head. A client who has undergone chest surgery should be taught to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power. Turning from side to side, raising and lowering the head, and flexing and extending the elbow on the affected side do not exercise the shoulder joint.

What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion?

Use a sterile catheter each time the client is suctioned. The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

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 assessment for which symptom?

dyspnea Dyspnea is a distressing symptom in clients with advanced cancer including metastatic carcinoma of the lung, previous radiation therapy, and coexisting COPD. Ascites does occur in clients with metastatic carcinoma; however, in the client with COPD and lung cancer, dyspnea is a more common finding. A pleural friction rub is usually associated with pneumonia, pleurisy, or pulmonary infarct.

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

the client with stridor who just received the first dose of an antibiotic The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. This may indicate an anaphylactic reaction to the antibiotic. The nurse must intervene to prevent anaphylactic shock. The airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the clients with improving chest pain and elevated blood pressure should be assessed.

A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect?

trace peripheral edema, previously +2 The therapeutic effect of furosemide is to mobilize excess fluid. The client's peripheral edema should decrease, indicated by changing from +2 to trace. As furosemide decreases fluid in the lungs, the client's crackles should decrease, not continue to progress. If furosemide is attaining a therapeutic effect, the blood pressure should decrease into normal range and the oxygen level should increase to above 90%.

An older adult's daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. What should the nurse tell the daughter?

"The follow-up for your father will be a chest X-ray every 6 months." Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an important component of the treatment plan. Serum markers (liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed tomography scan.

A client with asthma who has wheezing and shortness of breath asks the nurse if it is all right to use the salmeterol inhaler during exercise. What is the nurse's best response?

"No, this drug is a maintenance drug, not a rescue inhaler." Salmeterol is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol is used as the "rescue inhaler" for bronchospasms. Salmeterol can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking salmeterol twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for salmeterol include only asthma and bronchospasm induced by chronic obstructive pulmonary disease

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs?

"Take the albuterol first and follow with beclomethasone two times a day." The nurse instructs the client to administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue, which follows after 1 minute between puffs. Using a spacer device with an MDI provides the best delivery of medication to the lungs.

The nurse is caring for a client with emphysema. The client asks about the reason for persistent respiratory acidosis. What is the best response by the nurse?

"Your alveoli have lost elasticity, which causes retained carbon dioxide." Emphysema causes a loss of alveolar elasticity. The alveoli become hyperinflated with retained carbon dioxide, which leads to chronic respiratory acidosis. While the client with emphysema will experience increased work of breathing, it is the retained carbon dioxide that causes the respiratory acidosis. Narrowed bronchioles and increased mucus production are characteristic of chronic bronchitis, which causes hypoxemia, not respiratory acidosis.

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 One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia.

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?

600 mL of blood in the collection chamber in 1 hour 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.

A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber the nurse will mark to record the current drainage level.

A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the left.

The client is ready for discharge after surgery for a deviated septum. Which instruction would be appropriate?

Avoid activities that elicit Valsalva's maneuver. The client should be instructed to avoid any activities that cause Valsalva's maneuver (e.g., straining at stool, vigorous coughing, exercise) to reduce stress on suture lines and bleeding. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client's appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.

A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which action would help liquefy these viscous secretions?

Breathe humidified air. Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. Postural drainage may be helpful for respiratory hygiene but will not affect the nature of secretions. Vibration and percussion of the chest wall may be helpful for respiratory hygiene but will not affect the nature of secretions. Coughing and deep-breathing exercises may be helpful for respiratory hygiene but will not affect the nature of secretions.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings?

Bronchial edema and constriction have worsened. During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways have swollen and gas exchange is limited. If the attack is over and bronchial swelling has decreased, there would be audible breath sounds and no more wheezing. If the administered albuterol was effective, the wheezing would diminish and gas exchange would improve. Pulmonary edema results in bilateral crackles on auscultation.

A nurse is caring for a client following an elective bronchoscopy. Which intervention by the nurse is most appropriate?

Do not give the client anything by mouth until the gag reflex returns. 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 is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply.

Keep suction equipment available. Assess cough and gag reflexes after the procedure. Report hemoptysis, stridor, or dyspnea immediately. Suctioning equipment should be kept available to clear the airway and prevent aspiration. Preoperative sedation and local anesthesia depress the gag and cough reflexes, so the nurse must assess for the return of these reflexes after bronchoscopy. Hemoptysis, stridor, or dyspnea should be reported immediately, because these findings indicate respiratory distress possibly caused by a pneumothorax, a complication of bronchoscopy. The client should not eat immediately after the procedure. Food and fluid are withheld until the gag reflex returns. The client is sedated for the procedure. A bronchoscopy involves inserting a fiberoptic endoscope into the bronchi, not the stomach.

The nurse is assessing the client (see photo) who has recently returned from a 2-month mission in Africa. What type of respiratory protection is appropriate for the staff?

N95 particulate respirator Any type of blistering lesion, such as smallpox, requires extreme care to prevent exposure. Transmission-based precautions for smallpox includes airborne, droplet, and contact precautions. The N95 mask filters at least 95% of airborne particles. To prevent exposure through the respiratory tract, the N95 mask must be fitted and worn properly.

A client is using an over-the-counter nasal spray containing pseudoephedrine to treat allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to provide for the client?

Overuse of pseudoephedrine can lead to increased nasal congestion. Overuse of nasal spray containing pseudoephedrine can lead to rhinitis medicamentosa, which is a rebound effect causing increased swelling and congestion. Use of pseudoephedrine nasal spray does not cause infections or thrush. Pseudoephedrine is not addictive.

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. 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 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. 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.

If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first?

Reposition the airway. If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. A bag-mask device allows for delivery of 100% oxygen, but is difficult to manage if there is just one rescuer; ideally two persons are used to operate the bag-mask device, one to maintain the seal and the other to provide the ventilations. Compressions should be maintained at 100 per minute.

A chronically ventilated client requests that care be withdrawn. The client is competent and understands the consequences of this decision. The client is not depressed, but does not want to continue living in this way. What should the nurse consider in this situation? Select all that apply.

The client has the right to refuse medical treatment. The client's chart must be checked for a health care power of attorney. The physician must be notified of the request. The client has the right to refuse any treatment. In addition, there might be a power of attorney in the chart; therefore, the nurse should check the client's medical chart. The physician needs to be informed of the client's request. Withdrawing care must be supported by documentation/request. A family request is not is not enough without support of a living will.

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:

Vertigo. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

a client requiring assistance ambulating, who was admitted with a history of seizures The RN may safely delegate assistance ambulating for the client with a history of seizures to a nursing assistant. The RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse.

A 6-year-old child is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report?

antibiotic Staphylococcus. aureus is the most common causative pathogen of osteomyelitis; the usual source of the infection is an upper respiratory infection (URI) or skin lesion. The nurse anticipates an intravenous antibiotic as the essential medication. The nurse may have an anti-inflammatory medication as adjunct therapy. By decreasing the infection, the client may experience decreased pain; thus, not needing an analgesic. The nurse would administer an antipyretic if the child was febrile.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

bleeding The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first?

client experiencing tracheal deviation following a subclavian catheter insertion Tracheal deviation suggests possible tension pneumothorax, which is a medical emergency and needs to be evaluated immediately. Edema in a client with right-sided heart failure is a chronic condition and expected, it is not an emergency. Stabbing chest pain is expected with a pleural effusion and is also not an emergency situation. Pulmonary rehabilitation is completed by respiratory therapy and does not require the attention of the nurse.

The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the health care provider when the client has which symptom?

decreased breath sounds Diminished breath sounds during an acute asthma attack are a serious sign of airway obstruction, fatigue, and impending respiratory failure. Wheezing, coughing, and the production of sputum indicate the presence of airflow through the lungs and are less ominous symptoms.

When developing a discharge plan with a client with chronic obstructive pulmonary disease (COPD), what information should the nurse include in the plan? People with COPD:

develop respiratory infections easily. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

A client with pulmonary fibrosis is prescribed home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use?

home health nurse The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is responsible only for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they can't adequately evaluate the client's knowledge of home oxygen use.

The nurse is assessing a client with chronic obstructive pulmonary disease. Which finding requires immediate intervention?

inability to speak nability to speak could indicate respiratory distress. Pulsed lip breathing, while it is an abnormal finding is not indicative of respiratory distress. Distant heart sounds could indicate heart failure but are not indicative of any distress.

A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH?

increased respiratory rate The critically ill client with sepsis is at risk for decreased perfusion of tissues and organs, which leads to lactic acid production. This causes the client to experience metabolic acidosis. To correct the acidosis, the lungs eliminate carbonic acid by blowing off more CO2 via an increased respiratory rate. It is the respiratory system that compensates for metabolic acidosis, not the renal system. Blood pressure will be low in the client with sepsis, but blood pressure is not a compensatory mechanism for pH imbalances. While body temperature can affect acid base balance, this is not how the body compensates for metabolic acidosis.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important?

monitoring intake and output Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

Arterial blood gas analysis would reveal which finding related to acute respiratory failure?

pH 7.24 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 client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

partial pressure of arterial oxygen (PaO2) 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 nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed?

petrolatum gauze Gauze saturated with petrolatum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dry dressings or adhesive strips are not used.

A client who is intubated on mechanical ventilation develops subcutaneous emphysema. Which ventilator setting should the nurse anticipate being adjusted for this client?

positive end-expiratory pressure (PEEP) For a client being mechanically ventilated, subcutaneous emphysema occurs because the alveoli are overdistended and rupture, permitting air to escape into the surrounding tissues. PEEP keeps the alveoli open between breaths. Because subcutaneous emphysema has developed, the PEEP setting should be adjusted. The development of subcutaneous emphysema did not occur because of the ventilator rate, oxygen concentration, or number of assisted breaths set on the ventilator.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance?

respiratory acidosis s status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.

The health care provider (HCP) has prescribed pseudoephedrine. The nurse should instruct the client about which possible adverse effect of this drug?

restlessness 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.

A client has had a central venous pressure line inserted. The nurse should immediately report which sign to the health care provider?

sharp pain on the affected side Sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness indicate a pneumothorax, which can be a complication of inserting a central venous pressure line. The other findings are within normal limits.

Which finding in a client who is receiving albuterol would require a nurse to take immediate action?

stridor Stridor indicates partial airway obstruction, and requires immediate intervention. A pleural rub, crackles, and wheezes should be further assessed.

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign?

tingling in the arm A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.

The health care provider prescribes 0.4 mg of atropine sulfate and 75 mg of meperidine hydrochloride to be given intramuscularly to a client 1 hour before surgery. The stock ampule of atropine contains 0.8 mg/mL, and the stock ampule of meperidine contains 100 mg/mL. The two drugs are compatible and can be drawn up in one syringe. What is the combined volume of medication in the syringe?

1.25 mL The correct amount to administer is determined by using ratios, as follows:0.8 mg/1 mL = 0.4 mg/x mL0.8/x = 0.4x = 0.5 mL of atropine sulfate100 mg/1 mL = 75 mg/x mL100/x = 75x = 0.75 mL of meperidine hydrochloride0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

10 to 20 mcg/ml The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.

For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour?

22 The nurse should administer 22 ml/hour. To determine the number of units per milliliter: 25,000 units of heparin divided by 50 units/ml equals 500 ml of fluid. Because each milliliter of D5W contains 50 units of heparin and the nurse must deliver 1,100 units/hour, perform this calculation to determine the milliliters per hour of I.V. solution flow: 1,100 units/hour ÷ 50 units/ml = 22 ml/hour.

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?

Avoid rigorous aerobic exercise. 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. Aspirin inhibits platelet aggregation, reducing the ability of the blood to clot. The client should continue to take his antihypertension medication, ramipril. Posterior nasal packing should be left in place for 1 to 3 days.

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take?

Notify the physician immediately to have the physician determine client competency. Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.

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.

Obtain vital signs. Apply antiembolic stockings. Keep the client oriented. 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.

The nurse is caring for a client that is having an anaphylactic reaction. The client is wheezing, dyspneic, and cyanotic. Place the interventions in chronological order. All options must be used.

Provide supplemental oxygen. Administer epinephrine 1:1000 subcutaneously. Start a peripheral IV. Administer normal saline. Document interventions and response to treatment. Educate the client about prevention of anaphylaxis. Management depends on the severity of the reaction. Since the client is exhibiting respiratory distress, supplemental oxygen must be provided. Epinephrine, in a 1:1,000 dilution, is administered subcutaneously. Intravenous fluids are administered to maintain blood pressure and normal hemodynamic status. The nurse documents the interventions used, and the client's vital signs and response to treatment. The client who has recovered from anaphylaxis needs instruction about antigens that should be avoided and about other strategies to prevent recurrence of anaphylaxis.

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 to monitor closely for complications that include which of the following?

acute respiratory distress syndrome (ARDS) A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. ARDS refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan?

agrees to call the health care provider (HCP) if dyspnea on exertion increases. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the client should notify the HCP. It is not necessary to avoid being around others. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which way?

at a low flow rate The client with emphysema has a chronically elevated carbon dioxide level. As a result, the normal stimulus for breathing in the medulla becomes ineffective. Instead, peripheral pressoreceptors in the aortic arch and carotid arteries, which are sensitive to oxygen blood levels, stimulate respirations. This is in response to low oxygen levels that have developed over time. If the client receives high concentrations of oxygen, the blood level of oxygen will rise excessively, the stimulus for respiration will decrease, and respiratory failure may result. Oxygen is not cooled. Humidification or administration of the oxygen through nasal cannula will not prevent depressed ventilation if the flow rate of the oxygen is too high.

The nurse working in a skilled nursing home is evaluating a client that has completed a 10-day course of antibiotics three days ago for pneumonia. What assessments will the nurse need to notify the healthcare provider about? Select all that apply.

cough with phlegm change in level of consciousness A change in the level of consciousness and a cough with phlegm are abnormal assessments related to pneumonia. Clear breath sounds, pulse oximetry reading of 96%, and tympanic temperature 98.2°F (36.8°) are normal assessments indicating that the antibiotic may have helped manage the pneumonia symptoms.

For a client with a sucking stab wound in the chest wall, the nurse should first:

cover the wound with a petroleum-impregnated dressing. The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound.The nurse can next notify the health care provider. Starting oxygen therapy and preparing for endotracheal intubation may be necessary later, but neither has the same priority on admission as closing the wound.

The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client?

decreased breath sounds on the affected side A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. The nurse should not expect to hear wheezing on auscultation.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the

frontal and maxillary sinuses. After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

The nurse is caring for several clients on the respiratory unit who are receiving the β-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply.

irritability and nervousness tachycardia insomnia anxiety Albuterol is prescribed to prevent and treat wheezing, difficulty breathing, and chest tightness caused by lung diseases such as asthma and chronic obstructive lung disease (COPD). Irritability, nervousness, tachycardia, insomnia, and anxiety are common side effects of β-adrenergic agonist bronchodilators that result from sympathetic nervous system stimulation. The expected therapeutic effect of a bronchodilator is decreased dyspnea and slower (not increased) breathing. Increased somnolence does not occur with sympathetic nervous system stimulation.

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder?

pH 7.28, PaO2 50 mm Hg 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 an arterial pH of less than 7.35.

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 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.

A client has a newly positive Mantoux skin test but does not have active tuberculosis. The nurse should instruct the client to:

take isoniazid as prescribed. lients with newly positive skin tests are aggressively treated with isoniazid for about 9 months.The client with a newly positive Mantoux test requires prophylactic drug treatment; a blood test will not reveal tuberculosis at this time.Repeat skin testing should not be performed as it will always be positive.Skin tests do not convert to negative once a positive response has been obtained.

A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client?

using a cooling mist humidifer and administering dextromethorphan Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.

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." 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.

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication." The client requires additional teaching if he states that coworkers will need to take medication. If exposed and testing positive, medications would be required for coworkers. Contacts need to be tested for tuberculosis. However, a person in close contact with a person who's infectious is at greatest risk and should be definitely be checked. The client demonstrates effective teaching when stating a need to take medications for 9 to 12 months and that required laboratory tests while on medication.

A competent client requiring long-term mechanical ventilation privately tells a nurse that they want the ventilator withdrawn. Which response by the nurse is best?

"Tell me more about how you are feeling." Asking the client how they are feeling uses an open-ended question that encourages the client to express their feelings. Asking the client to consider their family is judgmental and is an inappropriate statement. Ventilation can be withdrawn according to the client's wishes. The nurse stating, "Now that I'm here" is unprofessional and would be inappropriate. Contacting the healthcare provider would be premature as the nurse needs more information.

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?

6 to 12 months 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.

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

Administer bronchodilators as prescribed. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

Which measure should the nurse perform when suctioning a tracheostomy tube?

Administer high concentrations of oxygen before suctioning the client. 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.

A client with chronic renal failure is being admitted with pulmonary edema. Which is the prioritynursing intervention?

Assess lung sounds and oxygen saturation level. A client with chronic renal failure who is admitted with pulmonary edema should have their lungs monitored as the priority. The client could have hyperkalemia, hypertension, or anemia, and these assessments should be completed as well. Recording accurate intake and output and monitoring daily weight would also be appropriate. However, respiratory status is the priority.

A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. What should the nurse instruct the client to do?

Avoid activities that elicit the Valsalva maneuver. The client should be instructed to avoid any activities that cause Valsalva's maneuver (e.g., constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture lines. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client's appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?

Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

Which health-promoting activity should the nurse teach the client who recently underwent a laryngectomy?

Cleanse the mouth three times a day 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.The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches (15 cm) deep, and other safety measures that will prevent water from entering the laryngectomy site.Moderate exercise may be beneficial, but an aggressive exercise program is not usually part of the plan of care.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The HCP must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?

Further assess the client for reinflation of the lung. A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?

Impaired gas exchange Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist. Impaired skin integrity, Activity intolerance, and Imbalanced nutrition: Less than body requirements (when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals.

The nurse is reconciling the prescriptions for a client diagnosed recently with pulmonary tuberculosis who is being admitted to the hospital for a total hip replacement (see medication prescription sheet). The client asks if it is necessary to take all of these medications while in the hospital. What should the nurse tell the client?

It's important to continue to take the medications because the combination of drugs prevents bacterial resistance." The nurse should tell the client that it is necessary to take all of these medications because combination drug therapy prevents bacterial resistance; they will be administered throughout the hospitalization to maintain blood levels. The HCP will review the prescriptions per hospital policy because the client is being admitted to the hospital; there is no duplication between any of the drugs being prescribed for this client. It is not necessary to ask the pharmacist to check for drug interactions as these drugs are commonly used together.

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure). The nursing policy manual recommends use of the gauze pad. What should the nurse do?

Make sure the gauze pad is dry and the client is in a comfortable position. The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse team leader should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad.

Which intervention will the nurse expect for a client with a positive tuberculin skin test?

Prepare the client for a chest X-ray. he tuberculin skin test is a screening tool to determine if the client has been exposed to TB. The next step would be to determine if any chest infiltrates exist. The sputum specimen is the only definitive diagnostic test and would only be necessary if the X-ray was positive. The rifampin would only be administered if the chest X-ray was positive. Thus the chest X-ray is the next intervention to be implemented for this client.

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax?

Sudden, sharp pain on the affected side. Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates a tension pneumothorax, which is a medical emergency.

Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?

Teach the client to splint the rib cage when coughing. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.

A client has been diagnosed with legionellosis (Legionnaires' disease). The client asks, "How did I get this?" Which response by the nurse is the most accurate?

The bacteria are inhaled from contaminated water droplets." Legionellosis is a pneumonia caused by the bacterium Legionella pneumophilia that thrives in water that is 95° to 115° F (35° to 46° C). When a building's hot water plumbing has water at this temperature, the bacteria thrive; then they may be transmitted via inhalation from air conditioning, showers, spas, and whirlpools. The bacteria are not transmitted via smoke or ceiling fan blades or by swallowing contaminated water.

A client with an endotracheal tube is being weaned from the ventilator. For which reason should the procedure be terminated?

The heart rate increased 20 beats/minute. The weaning process should be terminated if the client experiences an adverse reaction such as increase in heart rate of 20 beats/minute. The client being awake and alert and able to lift the head independently off the pillow indicates enough muscle strength and tone to maintain independent respirations. A diastolic blood pressure decrease of 6 mm Hg is not a reason to discontinue the weaning procedure.

Which assessment finding puts a client at increased risk for epistaxis?

cocaine use Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination?

a 75-year-old woman with diabetes Clients who have a chronic illness, have experienced a serious illness, reside in long-term care facilities, or are 65 years of age or older are encouraged to obtain pneumococcal and influenza vaccinations. Having angina or benign prostatic hypertrophy would not predispose a client to pneumonia or influenza. Pregnancy is not a contraindication, but this woman is not at high risk for these diseases.

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect

a drop in the client's heart rate. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by which indicator of oxygenation?

arterial blood gas (ABG) values. 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.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for

atelectasis. n a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise?

better elimination of carbon dioxide 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. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube Tubing that is coiled flat on the bed and secured without putting tension of the tube maintains a patent, free draining system. This prevents fluid accumulation and decreases the risk of infection, atelectasis, and tension pneumothorax. The other choices all have risks associated with becoming disconnected.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?

ineffective breathing pattern related to tissue trauma Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort. Remediation:

he nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client

mucous membranes Skin color does not affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they are affected by skin color.

The client is taking triamcinolone acetonide inhalant to treat bronchial asthma. The nurse should assess the client for:

oral candidiasis. 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 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 a chest tube insertion 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.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

using a Venturi mask to deliver oxygen as ordered A Venturi mask allows the nurse to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking 3 glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:

"I'll stop being contagious when I have a negative acid-fast bacilli test." A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test result for several days. The client will not have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

The health care provider prescribed intravenous naloxone to reverse the respiratory depression from morphine administration. After administration of the naloxone, what should the nurse do?

Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. The nurse should monitor the client's respirations closely for 4 to 6 hours because naloxone has a shorter duration of action than opioids. The client may need repeated doses of naloxone to prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the client's respiratory rate will be necessary. The client's dosage of morphine will be decreased or a new drug will be prescribed to prevent another instance of respiratory depression.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

Proceed to suction the client's tracheostomy. The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate healthcare, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a healthcare worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

The nurse is assessing a client who has a chronic obstructive respiratory disorder. Which finding should be immediately reported to the healthcare provider?

pedal edema Dependent pedal edema is a sign that cor pulmonale may be occurring, and indicates progression of the disease. Fingernail clubbing, decreased tactile fremitus, and barrel chest are expected findings with this disease.

An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is:

relax bronchial smooth muscle. Theophylline ethylenediamine is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease.Theophylline ethylenediamine does not reduce bronchial secretions or decrease alveolar elasticity.Theophylline ethylenediamine does increase strength of myocardial contractility, but this is not the action for which it is used.

The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia?

restlessness 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's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis?

risk for activity intolerance These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

Administer the salmeterol and then administer the triamcinolone. A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values (see report). Which finding is abnormal?

PaCO2 The normal range for PaCO2 is 35 to 45 mm Hg (4.7 to 6 kPa). Thus, this client's PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the health care provider (HCP) because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.

Clients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk?

physical and emotional stress 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 nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

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 Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

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?

decreased oxygen requirements 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.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must

encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

A client is receiving streptomycin to treat tuberculosis. What should the nurse evaluate to determine an adverse effect of the drug?

hearing loss Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate

high protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?

intermittent suction while withdrawing the catheter To prevent hypoxia, the nurse should use intermittent (not continuous) suction while withdrawing the catheter. Suctioning shouldn't last more than 10 seconds at a time. Neither intermittent nor continuous suctioning should be applied while the catheter is being advanced

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?

irregular heartbeat 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.

After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider?

laryngeal stridor 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.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.

A client with acute respiratory distress syndrome (ARDS) has become hypotensive and hypoxic. Which intervention is most appropriate?

placing client in the prone position Treatment of hypoxia is the priority. Of the interventions listed, prone positioning has been shown to improve oxygenation in clients with ARDS. Furosemide would not be used, as it would worsen the hypovolemia. Careful treatment of hypovolemia without causing fluid overload is in order. Dexamethasone or other corticosteroid given in low dose within the first 14 days of onset is helpful, but hypoxia takes priority. Clients become very anxious related to the worsening hypoxemia and dyspnea and may require antianxiety medication, like lorazepam.

The nurse is teaching a client about the pathophysiology of asthma. Place in chronological order the sequence of an asthma attack. All options must be used.

trigger by stimulus inflammation mucous production airflow limitation breathlessness acute asthma attack Asthma is triggered by a stimulus. The stimulus may be environmental, stress related, or medication related. Inflammation in the airways occurs as a response to the stimulus, followed by an increase in mucus production. The presence of inflammation and mucous narrow the bronchi, causing limited airflow. At this point, the client experiences breathlessness, chest tightness, and wheezing—all symptoms of an acute asthma attack.

The nurse has received lab reports for several clients undergoing care. Which set of arterial blood gas (ABG) results will the nurse investigate first?

pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L The ABG results pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L indicate respiratory alkalosis. The pH level is increased, the PaCO2 levels are decreased and the HCO3 is normal. The decreased PaO2 indicates this client is in respiratory distress. Therefore, the nurse would investigate this result first. Normal values are pH 7.35 to 7.45, PaCO2 35 to 45 mmHg, and HCO3- 22 to 26 mEq/L. Results of pH 7.35, PaCO2 48 mmHg, PaO2 91 mmHg, and HCO3- 28 mEq/L indicate a fully compensated respiratory acidosis, making this less urgent. Results of pH 7.47, PaCO2 43 mmHg, PaO2 99 mmHg, and HCO3- 29 mEq/L indicate metabolic alkalosis, which is not the priority. Results of pH 7.34, PaCO2 36 mmHg, PaO2 95 mmHg, HCO3- 20 mEq/L indicate mild metabolic acidosis, which would also be less urgent than the respiratory alkalosis.

A client with tuberculosis is taking isoniazid (INH). What should the nurse instruct the client to do to help prevent development of peripheral neuropathies?

Supplement the diet with pyridoxine (vitamin B6). INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A client diagnosed with tuberculosis is taking the prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. Although side effects are rare, the nurse should assess the client for which side effect of this drug combination?

hepatotoxicity The major side effect of these three drugs is liver toxicity. While the client is taking these drugs, the nurse should carefully monitor the client's liver function tests.Ototoxicity and nephrotoxicity are side effects of other drugs used to treat TB, such as streptomycin, kanamycin, and capreomycin.Optic neuritis can be a rare side effect of isoniazid.

Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)?

high-calorie, high-protein diet 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. There is no need for the client to eat bland, soft foods.

A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client:

is immunocompromised. An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories

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?

High oxygen concentrations may inhibit the hypoxic stimulus to breathe. lients 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.

The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. What additional assessment should the nurse make

obstruction of the airway Wheezing over one lung in the presence of a lung tumor is most likely caused by obstruction of the airway by a tumor. Exudate would be more likely to cause crackles. The client's history of smoking would not cause unilateral wheezing. Pleural effusion would produce diminished or absent breath sounds.

A nurse is reviewing arterial blood gas (ABG) results on four clients. Which results would the nurse report immediately to the healthcare provider?

pH 7.31, PaO2 84 mmHg, PaCO2 50 mmHg, HCO3 24 mEq/L, and O2 sat 90% This ABG of pH 7.31, PaO2 84 mmHg, PaCO2 50 mmHg, HCO3 24 mEq/L, and O2 sat 90% indicates uncompensated respiratory acidosis and would be reported to the healthcare provider immediately. The results pH 7.35, PaO2 82 mmHg, PaCO2 44 mmHg, HCO3 22 mEq/L, and O2 sat 95% are normal values. The results pH 7.45, PaO2 90 mmHg, PaCO2 28 mmHg, HCO3 32 mEq/L, and O2 sat 98% and pH 7.36, PaO2 86 mmHg, PaCO2 55 mmHg, HCO3 30 mEq/L, and O2 sat 90% both indicate fully compensated acid-base imbalances; they would not be the priority for reporting to the healthcare provider.

A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse?

Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Sims position is indicated for clients in the initial postoperative period. Sims position helps ensure patency of the airway by allowing secretions and blood to pool in the cheek and drain out the side of the mouth. If secretions are accumulating too quickly, suctioning may be required. Oxygen is given to improve oxygen saturation levels. If positioned in Fowlers, there will be more likelihood of swallowing the bloody secretions and becoming nauseated. The client's jaw is wired, so the airway cannot be inserted. If positioned supine, the client could aspirate. If positioned prone, there is more compression on the chest cage that could contribute to more shallow breathing.

A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal?

maintaining effective respirations As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation. Although maintaining an adequate circulatory volume, reducing anxiety, and relieving pain are pertinent for this client, they're secondary to maintaining effective respirations.

A client has had surgery for a deviated nasal septum. The client has returned from the postanesthesia care unit. What should the nurse do first?

Assess respiratory status. Immediately after nasal surgery, ineffective breathing patterns may develop as a result of the nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing for airway obstruction is a priority. Assessing for pain is important, but it is not as high a priority as assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not typically a priority nursing assessment after nasal surgery.

A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which actions? Select all that apply.

Elevate head of bed to 90 degrees. Administer diuretics as ordered. Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.

Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)? Select all that apply.

High humidity increases the effort of breathing. A bronchodilator with meter-dose inhaler should be readily available. Smoking cessation is important to slow or stop disease progression. High humidity has been shown to increase the work of breathing. Carrying a metered-dose inhaler can facilitate early intervention if bronchospasm and shortness of breath should occur. Smoking cessation is difficult to achieve but very important in preventing COPD progression. Pulmonary rehabilitation programs are a great source of support for health promotion and maintenance for clients with COPD. Both the pneumococcal and influenza vaccines can help protect again respiratory infections.

A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding?

The lung has fully expanded. Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been reestablished; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluctuation occurs because during inspiration intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space.

The nurse is caring for a client who states an increase in dyspnea. Which intervention would the nurse perform first?

check pulse ox Assessment is the first step in the nursing process. Assessing the pulse oximeter reading provides valuable information on the client's condition. Once the information is known, obtaining a breathing treatment or applying an oxygenated facemask, especially for a pulse oximeter reading under 90% is appropriate. Health care provider notification would also be necessary as oxygen is a medication requiring an order.

A client with severe acute respiratory syndrome privately informs the nurse of a desire not to be placed on a ventilator if the condition worsens. The client's partner and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to:

encourage the client to consider a living will or power of attorney. The nurse is obligated to act as the client's advocate. A living will or power of attorney would clearly define the client's wishes. The nurse should not discuss the issue with the client's family unless the client gives permission. Assuring the family and client that all possible measures will be taken opposes the client's wishes and does not demonstrate client advocacy.

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?

heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 indicates the early signs and symptoms of shock and the nurse should be most concerned about these.

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?

less difficulty breathing Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

sWhich nursing action does not aid in meeting the goal of clear breath sound

providing a minimum of 1,000 mL of fluid per day After surgery, the client should drink a minimum of 2,500 mL of fluid per day (not 1,000 mL) to keep secretions liquefied and easier to cough up and eliminate from the upper respiratory tract. The client should use pain medication before coughing. The client should use the incentive spirometer every 2 to 4 hours. The nurse should monitor the client's breath sounds and temperature to detect early signs of infection. The nurse should assist with early ambulation.

A client with bacterial pneumonia is to be started on IV antibiotics. The nurse should verify that which diagnostic test has been completed before administering the antibiotic?

sputum culture 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.

While suctioning a client's laryngectomy tube, the nurse should insert the catheter:

until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). 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.Coughing by a client does not necessarily indicate when to begin or stop suctioning.

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?

respiratory acidosis 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.