Chapters 20-24, 26, 30 Flashcards
A client is being seen in the emergency department for exacerbation of COPD. The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute
A 55 y.o. pt is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse
Asks the client, “What are your allergies?”
A client has asthma. Which of the following medication is a commonly prescribed mast cell stabilizer used for asthma?
Cromolyn sodium
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO 2 between the atmospheric air and the blood and between the blood and the cells
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of airinhaled or exhaled during each respiratory cycle?
Tidal volume
The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions?
Sitting on the edge of the bed
A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?
Bilateral lower lobes
High or increased compliance occurs in which disease process?
Emphysema
You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client?
Ventilation is breathing air in and out of the lungs.
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO 2 of 49 mm Hg and a HCO − of 28 mEq/L. The nurse reports to the 3 physician which finding?
Respiratory acidosis
The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?
Infection
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?
Assess the patient for a cough reflex.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
A 6-month-old male client and his elder brother, a 3-year- old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?
Eustachian tubes
While conducting the physical examination during assessment of the respiratory system, which of the following conditions does a nurse assess by inspecting and palpating the trachea?
Deviation from the midline
A client experiences a head injury in a motor vehicle accident. The client’s level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client’s respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
The pons
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
The nurse is calculating the patient’s smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient’s pack-years as which of the following?
22
Which ventilation-perfusion ratio is exhibited by a pulmonary emboli?
Dead space
Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright?
Orthopnea
In relation to the structure of the larynx, the cricoid cartilage is which of the following?
The only complete cartilaginous ring in the larynx
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
The nurse is completing a physical assessment of a patient’s trachea. The nurse inspects and palpates the trachea for which of the following?
Deviation from the midline
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid indicate?
Malignancy
The nurse is caring for a patient who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a patient with a respiratory disorder in order to do which of the following?
Manage decreased energy levels
Which of the following results in decreased gas exchange in older adults?
The alveolar walls contain fewer capillaries.
Which of the following is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
Which of the following is an age-related change associated with the respiratory system?
Decreased size of the airway
The clinical finding of pink frothy sputum may be an indication of which of the following?
Pulmonary edema
A patient with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which of the following does the nurse recognize is a deformity of the chest wall that occurs as a result of overinflation of the lungs in this patient population?
Barrel chest
The nurse is caring for a critically ill patient in the ICU). The nurse documents the patient’s respiratory rate as bradypnea. The nurse recognizes bradypnea is associated with which of the following conditions?
Increased intracranial pressure
The nurse is caring for a patient with suspected lung cancer. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan?w
PET scan
The nurse auscultates the lung sounds of a patient during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as which of the following?
Pleural friction rub
The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient?
Cyanosis
The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following?
Asking the patient to repeat “ninety-nine” as the nurse’s hands move down the patient’s thorax
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following?
Assess the patient for a cough reflex.
The nurse is caring for a patient complaining of chest discomfort. The patient’s admitting diagnosis is left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to help alleviate the discomfort?
Lying on the right side
A patient presents to the ED complaining of severe coughing episodes. The patient states the “episodes are more intense at night.” The nurse should suspect which of the following conditions based on the patient’s primary complaint?
Left-sided heart failure
The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following?
The lungs
Austin Holbritter, a six-month-old male, and his elder brother Matthew, a three-year-old male, are being seen in the pediatric clinic where you practice nursing. They are being seen by the physician for their third middle ear infection of this winter season. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?
Eustachian tubes
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low- pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:
assist the client to a sitting position on the edge of the bed, leaning over the bedside table.
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharnyx to the bronchi?
Trachea
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
In which position should the patient be placed for a thoracentesis?
sitting on the edge of bed
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?
Diagnosis of peripheral vascular disease
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
Wheezes
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?
Assess for a cough reflex.
Which of the following is an age- related change associated with the lung?
Increased thickness of the alveolar membranes
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI?
MRI can view soft tissues and can help stage cancers.
A son brings his father into the clinic, stating that his father’s color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client’s condition has lasted for more than 1 hour?
Cyanosis
A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?
Kussmaul respirations
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse’s priority?
Swallow reflex
The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?
Absent distal pulses
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
A client has a nursing diagnosis of “ineffective airway clearance” as a result of excessive secretions. An appropriate outcome for this client would be which of the following?
Lungs are clear on auscultation.
A nurse enters a client’s room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?
“I coughed that up about 8 hours ago.”
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?
Silent Unit
Silent Unit Mr. Sam Wallace, a 53-year-old male, is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?
Type II Cells
A patient has an order for arterial blood gases (ABG) to be drawn? Which of the following tests must be done prior to the procedure?
Allen Test
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?
Pulse Oximetry
Which of the following is a late sign of hypoxia?
Cyanosis
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
Impaired gas exchange
Which of the following results in decreased gas exchange in older adults?
The alveolar walls contain fewer capillaries.
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
The two methods of perfusion are the bronchial and pulmonary circulation
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client’s history will account for this finding?
Emphysema
A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?
Instructed the client to hold the breath
A student nurse is caring for a client who is severely anemic. The instructor asks the student how anemia affects the transport of oxygen to the cells. What would be the student’s best answer?
“The cells are denied adequate oxygen because most of the oxygen in the body is transported by the hemoglobin in red blood cells.”
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes.
An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
right upper lung
A 53-year-old client is seeing the physician today because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow up in 1 week if his voice has not improved. What is the primary function of the larynx?
producing sound
A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?
Respiratory rate of 44 breaths/minute
Which of the following is an age- related change associated with the respiratory system?
Decreased size of the airway
You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse’s best response?
The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe.
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client’s lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?
Crackles
You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?
They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
Difficulty in breathing
Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?
Manage decreased energy levels
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem.
A 13-year-old client at the pulmonary clinic where you practice nursing has an extensive history of asthma and is seeing the pulmonologist for her monthly appointment. What are the primary functions of the lungs? Choose all correct options.
- Ventilation
* Gas exchange
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client’s arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
hypotension
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
Regular breathing where the rate and depth increase, then decrease
In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?
Bradypnea
If concern exists about fluid accumulation in a client’s lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
What is the difference between respiration and ventilation?
Ventilation is the movement of air in and out of the respiratory tract.
Which diagnostic is more accurate in detecting malignancies than a CT scan?
PET scan
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
“Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe.
A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.
- Use of accessory muscles to breathe
* Purulent sputum with frequent coughing
A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?
Lateral diameter greater than anteroposterior diameter
Not every structure in the upper airway has a purpose in respiration. There are some structures whose role is immunological. Which of the following structures protect against infection? Choose all correct responses.
- Pharyngeal tonsils
* Palantine tonsils
A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say “ninety-nine” several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?
Bronchophony
The instructor in the anatomy and physiology class is talking about alveolar respiration. What would the instructor tell the class is the main purpose of alveolar respiration?
Determines amount of CO2 in the body
Which of the following is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub
Upon palpation of the sinus area, what would the nurse identify as a normal finding?
No sensation during palpation
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse’s priority?
Swallow reflex
A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?
Impaired gas exchange
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?
Don’t eat
In which position should the patient be placed for a thoracentesis?
Sitting on the edge of the bed
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
A nurse enters a client’s room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?
“I coughed that up about 8 hours ago.”
A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow- up in 1 week if his voice has not improved. What is the primary function of the larynx?
Producing sound
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?
Trachea
Which of the following is a deformity of the chest that occurs as a result of over inflation of the lungs?
Barrel chest
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi
A client with a respiratory condition is receiving oxygen therapy. While assessing the client’s PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilation tubing
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the draining in the collection chamber
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
continues assessing the client’s respiratory status frequently
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
By supplying a magic slate or similar device
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere?
Hyperbaric
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
The nurse is assisting a phys with an ET intubation for a client in respiratory failure. It is most important for the nurse to assess for:
symmetry of the client’s chest expansion
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a resp rate of 10 breaths per minute. These signs are associated with which condition?
hypoxia
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client’s bedside?
Manual Resuscitation bag
Which type of ventilator has a present volume of air to be delivered with each inspiration?
Volume-controlled
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10-15 minutes
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-sealed chamber
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 nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position Place the mouthpiece of the spirometer in the mouth Break air in through the mouth Hold breath for about 3 seconds Exhale air slowly through mouth
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
A client has a sucking stab wound to the chest. Which action should the nurse first?
Apply a wound dressing over the wound and tape it on three sides
A client has been place on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is
Tell me about what you are feeling
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
Which of the following is a potential complication of a low pressure in the ET cuff?
Aspiration pneumonia
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
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
10-15 seconds
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation fo this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10-15 minutes
A client with a respiratory condition is receiving oxygen therapy. While assessing the client’s PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
Which of the following is a correct endotracheal tube cuff pressure?
17 mm Hg
A home health nurse is visiting a home care client with advance lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a resp rate of 10 breaths/min. These signs are associated with which condition?
Hypoxia
Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?
Air leak
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)
Which of the following ventilator modes provides a combination o fmechanically assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV)
The nurse is preparing to perform chest physiotherapy (CPT) on a pt. Which of the following pt statement would indicate the procedure is contraindicated?
“I just finished eating my lunch, I’m ready for my CPT now.”
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
A client with a respiratory condition is receiving oxygen therapy. While assessing the client’s PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
The Family Nurse Practitioner is performing a physical examination of a client. The NP examines the clients anterior posterior and lateral chest walls. what is the NP assessing?
evidence of muscle weakness
You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes?
in the standing position.
The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?
absent distal pulses
You are a nurse in the radiology unit of your hospital. You are caring for a client who is scheduled for a lung scan. You know that lung scans need the use of radioisotopes and scanning machine. Before the perfusion scan, what must the client be assessed for?
iodine allergy
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure?
abstain from food for at least 6 hours before the procedure
The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell students purulent fluid indicates?
infection
The nurse is preparing a client for a diagnostic procedure. What should the nurse remember when providing information and appropriate explanations about diagnostic procedures to clients?
energy levels of clients may be decreased
Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client?
respiratory distress
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
warm and humidify inspired air
An 18 month old child is brought to the ED by their parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of the lung is the battery most likely to be in?
right upper lung
The student nurse is caring for a client who has serial sputum tests ordered. The student asks their instructor why the sputum tests have to be repeated on the successive days. What would be the instructors best response?
a negative sputum test does not always mean that there is no disease present, so more than one test may be needed
What happens to the diaphragm during inspiration?
it contracts and flattens
The instructor in the anatomy and physiology class is talking about alveolar respiration?
determines amount of CO2 in the body
You are studying for a physiology test over the respiratory system. What should you know about central in the medulla?
the respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
ventilation is the movement of air in and out of the respiratory tract
Perfusion refers to blood suply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods or perfusion?
The two methods of perfusion are the bronchial and pulmonary circulation.
A student nurse is caring for a client who is severely anemic. The instructor asks the student how anemia affects the transport of oxygen to the cells. What would be the students best answer?
the cells are denied adequate oxygen because most of the oxygen in the body is transported by the hemoglobin in red blood cells
What determines the amount of CO2 in the blood for the lungs to excrete?
the amount of hydrogen ions in the blood
The nurse is caring for a client in sickle cell crisis. The plan of care for this client includes giving oxygen by nasal cannula. What is the rational behind this nursing action?
the sickled red blood cells have damaged oxyhemoglobin so adequate oxygen does not reach the cells
You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess beside the physical and functional issues related to breathing?
how these issues affect the clients effort to breathe.
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe
You are caring for a client who is post sinus surgery. When you assess this client you ask them how many f ingers you are holding up. Why do you assess postoperative visual acuity?
to assess damage to the optic nerve
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
noisy breathing
You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements?
they prolong bleeding
Your client has had laryngeal surgery. What is as expected outcome in client?
the clients breathing patterns improve
A client comes into the ED with epistaxis. What intervention should you perform when caring for a client with epistaxis?
apply direct continuous pressure
You are an ED nurse caring for a client who experienced a trauma to the upper airway. What intervention should you perform to manage the risk of anxiety
assist in positive visualization
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?
encourage deep breathing every 2 hours
YOu are presenting about upper respiratory infections at an education event for a local community group. What should you be sure to include regarding cold tablets containing antihistamines?
they decrease discomfort temporarily
Clients who have had a laryngectomy are devastated by their loss of the ability to speak normally. WHy should a nurse provide extra time and support with these clients?
These clients need support and help in understanding and choosing an alternative method of speech
You are caring for a client who is status post nasal polypectomy. What would you instruct this client to report?
excessive swallowing
You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply.
alcohol
tobacco
industrial pollutants
Your client has just been diagnosed with laryngeal cancer. The client ask you what causes laryngeal cancer. What would be your best response?
research has shown that heredity contributes to having laryngeal cancer
A client come into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
laryngeal polyps
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently?
airway patency
You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physian and bring an endotracheal tube into the room. What do you suspect?
edema of the upper airway
What client would be most in need of an endotracheal tube?
comatose clients
you are a clinical nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. what may induce bronchitis?
chemical irritation
you are caring for a client with obstructive pulmonary disease. your nursing care includes diagnoses, outcomes, and interventions for what?
atelectasis
you are caring for a client with secondary pulmonary hypertension. what assessment finding would you expect?
orthopnea
you are caring for a client who has just been diagnosed with lung cancer. what is a cardinal sign of lung cancer?
mucopurulent sputum
the nurse is caring for a client with TB. why should the nurse always encourage a client with TB to perform active ROM exercises three times a day?
for maintaining muscle strength
your an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. you know that this client is at increased risk for which of the following:
acute respiratory distress syndrome
the new client on the unit was admitted with acute respiratory failure. whta are the signs and symptoms of acute respiratory failure?
sudden onset in client who had normal lung function
your client has just returned from the PACU after a rt lobe resection. The client has two chest tubes in place. you know that the anterior chest tube usually is placed to remove which of the following:
air
you are caring for a client with chronic respiratory failure. what are the signs and symptoms of chronic respiratory failure?
progressive loss of lung function associated with chronic disease
the nursing instructor is discussing pulmonary arterial hypertension with the nursing students. what would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension?
alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
For a client with impaired gas exchange, which position is best?
High Fowler’s
The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
The nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?
It helps prevent early airway collapse.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should a nurse take f irst?
Initiate oxygen therapy.
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) by I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86%, and he’s still wheezing. The nurse should plan to administer:
albuterol (Proventil)
A 69-year-old client comes to the emergency department with a history of productive cough, night sweats, and a 30-lb weight loss over the past 8 months. A diagnosis of tuberculosis is suspected. Which intervention is necessary for this client?
Place the client in a private room with negative air pressure, and implement airborne precautions
For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?
Teaching the client how to perform controlled coughing
A home health care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?
“I make sure my oxygen mask is on tightly, so it won’t fall off while I nap.”
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
Light-headedness or paresthesia
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 him closely for:
atelectasis
The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
Use diaphragmatic breathing.
A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcome indicates that the client has adequate respiratory function?
The client breathes at a rate of 16 to 20 breaths/minute.
The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:
the airways are so swollen that no air can get through
A 48-year-old client is admitted for suspected pulmonary emboli. Upon arrival in the intensive care unit, the client is alert and oriented. He insists on anxiously walking around the room. Which nursing actions take priority for this client?
Initiate bed rest with the head of the bed elevated at least 45 degrees, administer supplemental oxygen, and monitor the client’s respiratory status.
A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client?
“The ET tube will maintain your airway while you’re under anesthesia.”
A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?
“Do you smoke cigarettes, cigars, or a pipe?”
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client’s nose. What should the nurse do first?
Test the nasal drainage for glucose.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
“I should become involved in a weight loss program.”
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
Do not smoke and avoid being around others who are
Your client has had laryngeal surgery. What is as expected outcome in this client?
The client maintains an adequate caloric intake.
A 62-year-old male client with a history of chronic laryngitis arrives at the clinic complaining of a hoarseness “he can’t shake.” The nurse is aware that this client may be at risk for which of the following conditions?
Laryngeal cancer
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
Auscultate lung sounds.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
I was chewing ice chips all day long
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?
“Cover the stoma whenever you shower or bathe.”
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
bleeding
Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?
ensure mouth breathing
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:
empyema
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.”
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care?
“You must consume a diet rich in protein, such as chicken, f ish, and beans.”
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the waterseal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
What dietary recommendations should a nurse provide a patient with a lung abscess?
A diet rich in protein
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client’s care?
Encouraging increased fluid intake
You are assessing a client’s potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Pain in the calf
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing istrue?
A positive reaction indicates that the client has been exposed to the disease.
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
Negative
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3–) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is
primary drug resistance.
Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following?
Tense and relax muscles in lower extremities.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
Which action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered.
A patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest?
Paradoxical chest movement
A male patient newly diagnosed with COPD tells the nurse, “I can’t believe I have COPD, I only had a cough; are there other symptoms I should know about”? Which of the following is the nurse’s best response?
“Other symptoms you may develop are shortness of breath on exertion, and sputum production.”
The wife of a patient who was admitted 3 days ago with an exacerbation of chronic obstructive pulmonary disease (COPD) states that she is worried about her husband because he appears to be breathing “really hard.” The nurse performs a respiratory assessment. Which of the following findings would indicate a need for further interventions? (Select all that apply.)
• BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 degrees F
A client experiencing an asthmatic attack is prescribed methylprednisolone (Solu–Medrol) intravenously. The nurse:
Assesses fasting blood glucose levels
As status asthmaticus worsens, the nurse would expect which acid–base imbalance?
Respiratory acidosis
As a cause of death in the United States, chronic obstructive pulmonary disease (COPD) ranks
Fourth
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute
Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply.
- Tobacco smoke
- Occupational dust
- Air pollution
- Infection
- Second-hand smoke
A 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse
Asks the client, “What are your allergies?”
The nurse is caring for a patient with COPD. In COPD, the body attempts to improve oxygen-carrying capacity by increasing the amounts of red blood cells. Which of the following is the term for this process?
Polycythemia
Histamine, a mediator that supports the inflammatory process in asthma, is secreted by
Mast cells
Although many signs and symptoms lead to a diagnosis of emphysema, one symptom stands as the primary presenting symptom. Which of the following is the primary presenting symptom?
Dyspnea
A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute, despite receiving nasal oxygen at 2 L/minute. To improve the client’s shortness of breath, the nurse encourages the client to
Exhale slowly
A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client?
Increase walking distance around a city block without shortness of breath.
A nurse is assisting with a subclavian vein central line insertion when the client’s oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side
A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:
An abnormal distention of the air spaces with destruction of the alveolar walls
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
An inhaled beta2-adrenergic agonist
The nurse is reviewing metered-dose inhaler (MDI) instructions with a patient. Which of the following patient statements indicates the need for further instruction?
“I can’t use a spacer or holding chamber with the MDI.”
Which diagnostic is the most accurate in assessing acute airway obstruction?
Pulmonary function studies
A physician orders triamcinolone (Azmacort) and salmeterol (Serevent) 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.
To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations?
Streptococcus pneumonia and Haemophilus influenza
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?
Lung sounds
A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?
Emphysema
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
Take ordered medications as scheduled.
Which of the following is the strongest predisposing factor for asthma?
Allergy
The diagnosis of pulmonary hypertension associated with chronic obstructive pulmonary disease (COPD) is suspected when which of the following is noted? Select all that apply.
- Dyspnea and fatigue disproportionate to pulmonary function abnormalities
- Right ventricular enlargement
- Elevated plasma brain natriuretic peptide (BNP)
- Enlarge of central pulmonary arteries
Which of the following medications are contraindicated in acute asthma exacerbations?
intal
In which stage of COPD is the forced expiratory volume (FEV) less than 30%?
III
Emphysema is described by which of the following statements?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
The client is prescribed albuterol (Ventolin) 2 puffs as a metered–dose inhaler. The nurse evaluates client learning as satisfactory when the client
Positions the inhaler 1 to 2 inches away from his open mouth
A patient is being treated in the ED for respiratory distress, coupled with pneumonia. The patient has no past medical history. However, the patient works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which of the following orders based on immediate needs for the patient?
Administration of antibiotics
The nurse is assigned the care of a 30-year-old female patient diagnosed with cystic fibrosis (CF). Which of the following nursing interventions will be included in the patient’s plan of care?
Performing chest physiotherapy as ordered
Which of the following exposures accounts for the majority of cases with regard to risk factors for chronic obstructive pulmonary disease (COPD)?
Exposure to tobacco smoke
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. This change occurred because:
the airways are so swollen that no air can get through
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
A nursing student knows that there are three most common symptoms of asthma. Choose the three that apply.
- Cough
- Dyspnea
- Wheezing
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as
Atelectasis
A client is diagnosed with a chronic respiratory disorder. After assessing the client’s knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
anxiety
A nurse is assisting with a subclavian vein central line insertion when the client’s oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side
Histamine, a mediator that supports the inflammatory process in asthma, is secreted by
Mast cells
Which of the following would not be considered a primary symptom of COPD?
weight gain
Which of the following is true about both lung transplant and bullectomy?
Both are aimed at improving the overall quality of life of a patient with COPD.
A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. The nurse knows this would probably be
Albuterol
The classification of Stage I of COPD is defined as
mild COPD
A patient with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this patient includes which of the following?
Implementing measures to clear pulmonary secretions
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
“Weigh yourself daily and report a gain of 2 lb in 1 day.”
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 for this client?
High-protein
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute
After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options.
- Alter smooth muscle tone
- Increase oxygen distribution
- Reduce airway obstruction
Emphysema is described by which of the following statements?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
Following are statements regarding medications taken by a patient diagnosed with COPD. Choose which statements correctly match the drug name to the drug category. Select all that apply.
- Ciprofloxacin is an antibiotic.
- Prednisone is a corticosteroid.
- Albuterol is a bronchodilator.
A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86%, and he’s still wheezing. The nurse should plan to administer:
albuterol (Proventil)
A patient is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in patient teaching prior to discharge?
Application of graduated compression stockings
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is which of the following?
Contrast phlebography
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking?
Intermittent claudication
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?
Constant, intense back pain and falling blood pressure
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?
Stop smoking
Which of the following is the most common site for a dissecting aneurysm?
Thoracic area
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he’s stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?
Taking daily walks
Which of the following are characteristics of arterial insufficiency?
Diminished or absent pulses
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication
Which of the following statements is accurate regarding Reynaud’s disease?
Episodes may be triggered by unusual sensitivity to cold.
A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?
“I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”
You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect?
Aortic aneurysm
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine if the students understand the pathophysiology of the disease, the instructor asks, “What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?”
50
You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?
Atherosclerosis
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client’s care, which goal should the nurse keep in mind as she formulates interventions?
Stabilizing heart rate and blood pressure and easing anxiety
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess?
Peripheral pulses every 15 minutes following surgery
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?
“I have my wife look at the soles of my feet each day.”
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?
Intermittent claudication
A nurse is assessing a client’s right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?
Numbness, cool skin temperature, and pallor
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?
Raynaud’s disease
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis?
Teach the patient how to apply a graduated compression stocking.
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?
Elevate the legs periodically for at least 15 to 20 minutes.
Which of the following are risk factors for venous disorders of the lower extremities?
Obesity
Which of the following observations regarding ulcer formation on the patient’s lower extremity indicates that the ulcer is a result of venous insufficiency?
Border of the ulcer is irregular
Which of the following is accurate regarding Raynaud’s disease?
Episodes may be triggered by unusual sensitivity to cold.
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics?
Diminished or absent pulses
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes
a vasospasm
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?
Demonstrate how to apply and remove elastic support stockings.
A home health nurse is seeing an elderly male client for the f irst time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?
Venous insufficiency
The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:
decreases venous congestion
Which of the following terms refers to enlarged, red, and tender lymph nodes?
Lymphadenitis
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?
Participate in a regular walking program.
