Respiratory Flashcards
The nurse is caring for a client
with a diagnosis of pneumonia. Over the past 24 hrs, the nurse observes that the client has been requiring increasing amounts of supplemental oxygen to maintain the same level of oxygenation. The best intervention at this time is to:
Perform a more extensive pulmonary physical assessment.
The nurse considers which of
the following to be the priority item in discharge teaching for a client has chronic bronchitis.
Smoking cessation
A client has returned to the
clinic 72 hrs hrs following a TB skin test with an induration of 5-6 mm at the administration site. The client is visibly upset and and states: “I can’t believe I have TB!” Which statement by the nurse is appropriate?
“This finding does not confirm TB; it may indicate a recent exposure to tuberculosis.”
pH: 7.23
PaCO2: 63
PaO2: 64
HCO3: 26
Respiratory acidosis
Hypercarbia
Uncompensated
Hypoxemia
A client has a right chest tube following a thoracotomy. When assisting the client to ambulate, the nurse should use what measure to maintain functioning of the closed chest drainage system?
Keep collection device below the level of the chest.
A client is brought to the
Emergency Department following a motor vehicle collision with a tree. Which finding suggests to the nurse that the client has experienced a tension pneumothorax?
Tracheal deviation
The nurse is doing an admission assessment on a client who reports a gradual increase in SOB over at least the past several months. The client denies smoking and reports no hx of smoking. The nurse asks about the clients occupational hx because:
Exposure to occupational hazards may occur years before the onset of symptoms.
When auscultating breath sounds in the client with an acute asthma episode, the nurse uses which of the following to guide interpretation of severity of findings.
Wheezing may be absent with severe airway obstruction.
The nurse is caring for a patient
in the short procedure unit (SPU) following a bronchoscopy using moderate (conscious) sedation. Prior to discharge the client, has achieved which of the following priority outcomes?
Demonstrates an intact gag reflex
Rationale: An intact gag reflex indicates that topical sedation has lost its effect and the client is able to swallow, a major safety consideration prior to discharging the client from the healthcare facility (option 2). The ability to swallow precedes consumption of oral intake (option 4) and coincides with the return of the cough and gag reflex. Knowing symptoms to report to the physician following discharge is important (option 1), but the physiological condition following a bronchoscopy takes priority in this case. Fever, if present, may take hours to days to resolve, may be unrelated to the bronchoscopy and may have been present at the onset of the procedure (option 3).
Cognitive Level: Analysis
Client Need: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Evaluation
Content Area: Adult Health: Respiratory
Strategy: Note that a critical word in the question is priority. This tells you that more than one option may be a correct nursing action but that one is more important than the others. Apply the ABCs (airway, breathing, and circulation). Recall that an intact airway always takes precedence over other assessments.
Airway management
Goal is to maintain patient airway
The nurse is caring for a client diagnosed with right middle lobe pneumonia. The nurse should perform which of the following interventions to mobilize secretions?
Assist client to use incentive spirometer hourly.
Rationale: Helping clients deep breathe or use the incentive spirometer promotes maximum lung expansion, mobilizes secretions, and encourages cough (option 4). Antibiotics are given for bacterial pneumonia to eradicate the infecting organism; however, they do not mobilize secretions (option 1). Fluids and humidification liquefy secretions making them easier to mobilize; if they are limited, the client can develop a mucous plug (option 2). Clients with pneumonia are placed in the Fowler’s position to maximize lung expansion; the prone position may be used in clients with ARDS and refractory hypoxemia (option 3).
Cognitive Level: Application
Client Need: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Content Area: Adult Health: Respiratory
Strategy: Review the indications for each of the distracters. The answer selected must have a primary purpose of mobilizing or liquefying secretions.
Head & Jaw position:
Upper airway obstruction is often caused by?
Loss of local muscle tone or a foreign object
Head & Jaw position:
Open airway by?
Head tilt and anterior chin lift maneuver
Head & Jaw position:
In individuals with suspected neck injury, do not perform head tilt. How do you open airway?
Anterior chin displacement and/ or jaw thrust
Airway management
Goal is to maintain patient airway
Head & Jaw position:
Upper airway obstruction is often caused by?
Loss of local muscle tone or a foreign object
Head & Jaw position:
Open airway by?
Head tilt and anterior chin lift maneuver
Head & Jaw position:
In individuals with suspected neck injury, do not perform head tilt. How do you open airway?
Anterior chin displacement and/ or jaw thrust
Head & Jaw position:
Perform Heimlich maneuver in individuals who are?
Conscious with suspected foreign body obstruction
5 Artificial Airways?
Oropharyngeal airway Nasopharyngeal airway Endotracheal intubation Tracheostomy Cricothyrotomy
Oropharyngeal airway?
Maintains airway patency by preventing posterior tongue displacement
Oropharyngeal airway is intended only for?
Unconscious individuals because of risk for vomiting or laryngeal spasms
Oropharyngeal airway must be?
Sized for the individual
Oropharyngeal airway, assess
Oral cavity for?
Foreign body or vomitus
For an Oropharyngeal airway, a tongue blade may be needed to temporarily?
Displace tongue during insertion
Nasopharyngeal airway?
Maintains airway patency via nasal route in individuals who are semi- conscious or in whom placement of Oropharyngeal airway is not feasible
Head and Jaw position must be maintained independent of airway placement
Oropharyngeal airway &
Nasopharyngeal airway
A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to?
Avoid vigorous nose blowing and strenuous activity
A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to?
Avoid vigorous nose blowing and strenuous activity
A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to?
Avoid vigorous nose blowing and strenuous activity
A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to?
Avoid vigorous nose blowing and strenuous activity
Head & Jaw position:
Perform Heimlich maneuver in individuals who are?
Conscious with suspected foreign body obstruction
