Respiratory System

78問 • 1年前

問題一覧

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx?

Residual

A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume?

Exhaled after there is a normal inspiration

A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction?

Blowing vigorously into the mouthpiece

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions?

Tidal volume

A nurse identifies that a client’s hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin?

PCO2

What nursing action will limit hypoxia when suctioning a client’s airway?

Apply suction only after catheter is inserted.

A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via a nasal cannula?

Receives many visitors while sitting in a chair

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

Orthopneic

A client is admitted with suspected atelectasis. Which clini- cal manifestation does the nurse expect to identify when assessing this client?

Diminished breath sounds

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?

Remove the air that is present in the intrapleural space

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?

Palpate around the tube insertion sites for crepitus

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

Check the tube to ensure that it is not kinked.

After a laryngectomy a client is concerned about improving the ability to communicate. What topic should the nurse include in a teaching plan for the client?

Esophageal speech

A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse’s teaching about activities and the stoma is understood?

Water sports

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client’s history and present status?

Encouraging increased fluid intake

A nurse is caring for clients whose histories include various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider?

Result from streptococcal infections that enter via the upper respiratory tract

A client is admitted to the intensive care unit with acute pulmonary edema. Which rapidly acting intravenous diuretic should the nurse anticipate will be prescribed?

Furosemide (Lasix)

What nursing action will most help a client obtain maximum benefits after postural drainage?

Encourage coughing deeply.

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, “How could this have happened?” What likely cause of the spontaneous pneumothorax should the nurse’s response take into consideration?

Rupture of a subpleural bleb

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client?

Carbon dioxide retention

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, what action should the nurse take?

Give oxygen at 2 L per minute via nasal cannula.

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?

Air will move from the lung into the pleural space

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply.

Shortness of breath, Unilateral chest pain

What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia?

Loss of aerating surface

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. For which clinical indicators should the nurse closely observe the client? Select all that apply.

Drowsiness, Mental confusion

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm?

The residual capacity of the lungs has been increased.

While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action?

Withhold the drug until additional orders are obtained.

What is the priority goal for a client with asthma who is being discharged from the hospital?

Demonstrates use of a metered-dose inhaler

A client with a long history of asthma is scheduled for surgery. What information should be included in preopera- tive teaching?

There is an increased risk of respiratory tract infections.

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do?

Inhale completely and then blow out as hard and as fast as possible through the mouthpiece

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?

Decreased filling of the right heart

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?

Palpate the surrounding area for crepitus.

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

59-year-old who had a knee replacement

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

Obese client with leg trauma

A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. What conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse?

Appropriate, because early eating or drinking after such a procedure may cause aspiration

A client has a bronchoscopy in the ambulatory surgery unit. What action should the nurse take to prevent laryngeal edema?

Keep the client in the semi-Fowler position.

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion?

Extension of cancerous lesions

A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph?

Cavities caused by caseation

An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood- tinged productive cough. The health care provider suspects that the client has tuberculosis and orders a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed.

2,3,5,1,4

A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? Select all that apply.

Fatigue, Hemoptysis, Night sweats

A client who is taking rifampin (Rifadin) tells the nurse, “My urine looks orange.” What action should the nurse take?

Explain this is expected.

What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuber- culosis?

Sputum is free of acid-fast bacteria.

What interventions should the nurse anticipate will be ordered for a client who has a leak of the thoracic duct following radical neck surgery? Select all that apply.

Bed rest to conserve energy, Chest tube to drain the fluid, Total parenteral nutrition to boost immune defenses

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. For which clinical indicator should the nurse assess the client?

Restlessness

What should the nurse include in the plan of care for a client who just had a total laryngectomy?

Suctioning the tracheostomy tube whenever necessary

Which nursing action is important when suctioning the secretions of a client with a tracheostomy?

Initiate suction as the catheter is being withdrawn.

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client?

Expectoration of blood

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is impor- tant when suctioning the endotracheal tube?

Hyperoxygenate with 100% oxygen before and after suctioning

In the first 2 1/2 hours after a radical neck dissection, 40 mL of medium red, bloody fluid is obtained from the client’s drain- age system. What should the nurse do? Select all that apply.

Take vital signs, Notify the health care provider.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

Hemoptysis, Night sweats

A nurse must administer streptomycin 1 g IM to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number.

2 ml

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

Encourage coughing and deep breathing

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first?

Mental confusion

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client?

Monitor oxygen saturation levels when eating.

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply.

Prevent the client’s blanket from covering the adaptor’s orifices., Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client’s anxiety level?

Cannula

A client who has acquired immunodeficiency syndrome develops bacterial pneumonia. On admission to the emergency department, the client’s PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?

Notify the health care provider.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning

A nurse is involved in an international committee to address global health problems. What suggestion is most appropri- ate for the nurse to make to best meet the challenge associ- ated with a potential emerging influenza pandemic?

Establish a global surveillance plan

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action is the first line of defense against an emerging influenza pandemic?

Reporting surveillance findings to appropriate public health officials

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds

Thenurseiscaringforaclienthospitalizedwithacute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

A hyperinflated chest noted on the chest x-ray, Decreased oxygen saturation with mild exercise

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse include on the list? Select all that apply.

Activities should be resumed gradually., A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated, Respiratory isolation is not necessary, because family members already have been exposed., Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, would the nurse immediately report to the primary health care provider?

Bronchospasm

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

Pain, especially with inspiration

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinc- tive sign of flail chest?

Paradoxical chest movement

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has under- stood the information if the client makes which statement?

“I won’t be contagious after 2 to 3 weeks of medication therapy.”

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse would wear which items when performing this care?

Particulate respirator, gown, and gloves

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse would assess the client for which expected finding?

Dyspnea

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client in- dicates to report which early sign of exacerbation?

Shortness of breath

The nurse is taking the history of a client with oc- cupational lung disease (silicosis). The nurse would ask the client whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse would check the results of which diagnostic test that will confirm this diagnosis?

Sputum culture

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS