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Chapter 29 Respiratory
Terms in this set (32)
. Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)?
A. Client with allergic rhinitis scheduled for skin testing
B. Client with emphysema who needs teaching about pulmonary function testing
C. Client with pancreatitis who needs a preoperative chest x-ray
D. Client with pleural effusion who has had 1200 mL removed by thoracentesis
Client with pleural effusion who has had 1200 mL removed by thoracentesis
An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN?
A. Administer the purified protein derivative (PPD) for tuberculosis testing.
B. Assess vital signs and the puncture site after thoracentesis.
C. Monitor oxygen saturation using pulse oximetry every 4 hours.
D. Plan client and family teaching regarding upcoming pulmonary function testing.
Plan client and family teaching regarding upcoming pulmonary function testing.
A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU?
A. Assess breath sounds.
B. Check gag reflex.
C. Determine level of consciousness.
D. Monitor blood pressure and pulse.
Monitor blood pressure and pulse.
The RN has received report about all of these clients. Which client needs the most immediate assessment?
A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes
C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago
D. Client with pleural effusion who has decreased breath sounds at the right base
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule?
A. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%
B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test
C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment
D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea
Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%
Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema?
A. Barrel-shaped chest
B. Bronchial breath sounds heard at the bases
C. Hyperresonance to percussion of the chest
D. Ribs lying horizontal
Bronchial breath sounds heard at the bases
People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply.
B. Coal miners
D. Furniture refinishers
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)?
A. Administer bronchodilator medication on call.
B. Encourage clear fluid intake 12 hours before the procedure.
C. Ensure no smoking 6 hours before the test.
D. Provide supplemental oxygen as testing begins.
Ensure no smoking 6 hours before the test.
The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer?
A. Class I, can perform perform manual labor
B. Class II, can perform desk job
C. Class III, minimally employable
D. Class IV, must remain at home
Class II, can perform desk job
A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention?
A. Blood in the sputum
B. Mucoid sputum
C. Pink frothy sputum
D. Yellow sputum
Pink frothy sputum
A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest?
A. Adventitious breath sounds
C. Oxygenation status
D. Respiratory excursion
Adventitious breath sounds
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention?
A. Client with acute allergic reaction
B. Client with dyspnea on exertion
C. Client with lung cancer with cough
D. Client with sinus infection with fever
Client with acute allergic reaction
The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds?
C. Pleural friction rub
In the older adult client, which respiratory change does not require further assessment by the nurse?
A. Increased anteroposterior (AP) diameter
B. Increased respiratory rate
C. Shortness of breath
D. Sputum production
Increased anteroposterior (AP) diameter
In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO3− of 22. What action does the nurse need to take first?
A. Call the physician.
B. Encourage the client to slow his breathing rate.
C. Nothing. These results are within the normal range.
D. Provide oxygen support.
Encourage the client to slow his breathing rate.
The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first?
A. Assess the puncture site for drainage.
B. Implement NPO (nothing by mouth) status.
C. Monitor for signs of anaphylaxis.
D. Perform aggressive chest physiotherapy.
Implement NPO (nothing by mouth) status.
Why are the turbinates important?
A. They decrease the weight of the skull on the neck.
B. They increase the surface area of the nose for heating and filtering.
C. They move inspired particles from nose to throat for removal.
D. They separate two nasal passages down the middle.
They increase the surface area of the nose for heating and filtering.
A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords?
A. Arytenoid cartilage
D. Palatine tonsils
Where does gas exchange occur?
The client has a fever of 40° C. In which direction, if any, will this shift the oxyhemoglobin dissociation curve?
B. To the left
C. To the right
D. Will not shift
To the right
Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma?
A. Brother is allergic to peanuts.
B. Father is obese.
C. Mother is diabetic.
D. Sister is pregnant.
Brother is allergic to peanuts.
Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?
A. Client with pain on deep inspiration
B. Client with pain on palpation
C. Client with pain radiating to the shoulder
D. Client with pain that is rubbing in nature
Client with pain radiating to the shoulder
The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse?
A. Client who is short of breath after walking up two flights of stairs
B. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test
C. Client with sore throat and fever of 39° C oral
D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis?
A. Encourage client to ask questions and verbalize concerns.
B. Leave client alone to deal with his own feelings.
C. Medicate client with diazepam (Valium) for anxiety every 8 hours.
D. Provide journals about cancer treatment.
Encourage client to ask questions and verbalize concerns.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis?
B. Chest x-ray
C. Computed tomography (CT) scan
Computed tomography (CT) scan
You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action?
A. Call the Rapid Response Team.
B. Give methylene blue 1% 1 to 2 mg/kg by IV injection.
C. Administer oxygen.
D. Notify the physician immediately.
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?
D. Pulmonary embolism
How does atelectasis reduce gas exchange?
A. Airway obstruction
B. Reduced alveolar surface area
C. Failure of pulmonary circulation to fully perfuse lung tissue
D. Increased bronchial secretions filling the alveoli with fluid rather than with air
Reduced alveolar surface area
The 60-year-old client's smoking history includes smoking 2 packs of cigarettes per day since the age of 15 until the age of 40, and then smoking 3 packs per day to the present. How does the nurse document this smoking history?
A. 45 pack-years
B. 80 pack-years
C. 90 pack-years
D. 110 pack-years
Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). Ages 15 to 40 is 25 years x 2 packs per day = 50 pack-years. From ages 40 to 60 is 20 years x 3 packs per day = 60 pack years. 50 + 60 = 110.
In performing a chest assessment, the nurse observes or determines all of the following findings in a 70-year-old client. Which finding indicates to the nurse that the client may have an increased residual lung volume?
A. Exhalation is twice as long as inhalation.
B. Breath sounds are absent at the lung edges.
C. The intercostal spaces measure 4 centimeters.
D. Vibrations can be felt on the chest wall when the client speaks.
The intercostal spaces measure 4 centimeters.
The expected distance between the ribs is the width of the client's fingerbreadth, or about 2 centimeters. Distances greater than this are abnormal and usually indicate some degree of air trapping that causes an increased residual lung volume.
Reference: p. 555, Physiological Integrity
The client's oxygen saturation by pulse oximetry on the finger is 84%. What is the nurse's best first action?
A. Recheck the value on the forehead.
B. Assess the client's cognitive function.
C. Notify the Rapid Response Team immediately.
D. Apply supplemental oxygen by mask or nasal cannula.
Recheck the value on the forehead.
Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.
Reference: p. 556, Safe and Effective Care Environment
The client, in a panicky voice, tells the nurse during a thoracentesis that he feels as if he is being pushed off the table. What is the nurse's best response?
A. Stop the procedure to administer an anxiety-reducing drug.
B. Remind the client not to talk or breathe during the procedure.
C. Reassure the client this is a normal sensation as the needle is inserted into the chest cavity.
D. Relay this information to the health care provider performing the procedure so that the needle can be repositioned.
Reassure the client this is a normal sensation as the needle is inserted into the chest cavity.
The tissues of the thorax can be thick, and significant pressure may need to be applied to insert the needle. The client can indeed feel as though he is being pushed. This is a normal sensation and does not indicate a problem. Reassure the client first, then remind him not to move.
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