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The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?
Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client.
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?
Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway.
(A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client)
For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?
Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.
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.
-Clients 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.
Care of the chest tube?
Milking of chest tubes is not routinely recommended but, if performed, would be the responsibility of the nurse.The collection container should not be raised to bed height because this can cause fluid to flow back toward the client.Chest tubes should not be secured to the bed linens because they could be pulled on and potentially disconnected when the client moves and turns in bed.
A nurse is assigned to triage the care of four clients. Which client should the nurse assess first?
client with a sore throat who now has a muffled voice and is drooling
client with a "scratchy throat" and a positive rapid strep antigen test
client with throat cancer who has severe fatigue following radiation therapy
client with a history of a total laryngectomy whose stoma is red and inflamed
client with a sore throat who now has a muffled voice and is drooling
(The clinical manifestations of a muffled voice and drooling suggest a possible peritonsillar abscess that could lead to an airway obstruction.)
The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of:
(Hyperventilation causes the client to blow off more acid in the form of CO2, and therefore makes the body more alkalotic)
What is the antidote for warfarin?
Vitamin K (phytonadione).
What is the antidote for heparin?
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.
The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?
ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen.
What is the normal PaO2 level?
When teaching a client with chronic obstructive pulmonary disease to conserve energy, what instruction should the nurse give the client about breathing when lifting heavy objects?
exhaling through pursed lips.
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in the teaching?
"Cover the stoma with a loose plastic cloth whenever you shower or bathe."
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia (increased PaCO2), hypoventilation, and hypoxemia
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
What is vasovagal syncope?
occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. It may also be called neurocardiogenic syncope. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly.
After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:
depriving the client of sufficient oxygen supply.
-After suctioning, the client should rest at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing.
-Intermittent suctioning prevents oxygen deprivation.
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?
-A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed.
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."
-administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid (-one and -ide) to the lung tissue, which follows after 1 minute between puffs.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
The nurse is assessing the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which finding is expected?
coarse crackles and rhonchi
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.
((constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture lines)
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
When administering atropine sulfate preoperatively to a client scheduled for lung surgery, what should the nurse tell the client?
"This medicine will make your mouth feel dry."
The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be?
to have the client breathe into a paper bag
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
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:
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.
A nurse is reviewing orders for a client having an acute asthma attack. Which medication should the nurse administer?
-albuterol 2.5 mg per nebulizer
Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks
What are some medications used for long-term control of asthma?
methylprednisolone 60 mg I.V.
salmeterol 50 μg per dry-powder inhaler
triamcinolone two puffs per metered-dose inhaler
A nurse is completing annual cardiopulmonary resuscitation training. The class instructor states that a client has fallen off a ladder and is lying on the back. The client is unconscious and not breathing. What technique should the nurse use to open the client's airway?
If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should be positioned at the client's head and rest the thumbs on the client's lower jaw, near the corners of the mouth. The nurse should then grasp the angles of the lower jaw with the fingers and lift the jaw forward.
A client with emphysema is at a greater risk for developing what acid-base imbalance?
Chronic Respiratory acidosis
Impaired gas exchange, so the client would retain CO2
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. How should the nurse interpret this finding? Fluctuation means that:
the chest tube system is functioning properly.
-If an obstruction were present in the chest tube, fluid fluctuation would be absent.
-A leak in the system is indicated when bubbling occurs in the water seal column.
What is a serious adverse effect of streptomycin (antibiotic) therapy?
Decreased hearing acuity indicates ototoxicity,
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client:
uses the sternocleidomastoid muscles.
(Use of accessory muscles indicates worsening breathing conditions)
A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client?
(Impaired gas exchange! client retains CO2)
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.
A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:
Acetylcysteine must be used cautiously in a client with asthma because it
May cause bronchospasm
(It's a mucolytic agent that decreases the viscosity of respiratory secretions)
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?
Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., Mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV).
What is the usual duration of prophylactic isoniazid therapy for pulmonary tuberculosis?
6 to 12 months
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