Respiratory Mix Flashcards
1
Q
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings?
Select all that apply.
- Excessive bubbling in the water seal chamber
- Vigorous bubbling in the suction control chamber
- Drainage system maintained below the client’s chest
- 50 mL of drainage in the drainage collection chamber
- Occlusive dressing in place over the chest tube insertion site
- Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
A
The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client’s chest allows gravity to drain the pleural space.
2
Q
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?
1.
Stay very still.
2.
Exhale very quickly.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
A
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
3
Q
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?
1.
Do nothing, because this is an expected finding.
2.
Check for an air leak, because the bubbling should be intermittent.
- Increase the suction pressure so that the bubbling becomes vigorous.
- Clamp the chest tube and notify the health care provider immediately.
A
Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider’s prescription.
4
Q
Normal Carbon monoxide levels are between
A
1-10%
5
Q
Mild carbon monoxide poisoning is between __________% and results in
A
11-20%; Flushing, headache, decreased visual activity, decreased cerebral functioning, slight breathlessness
6
Q
Moderate carbon monoxide poisoning occurs between __________% and manifestations include
A
levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia
7
Q
Severe carbon monoxide poisoning levels occur between………..
manifestations include
A
41-60%
coma, seizures,cardiopulmonary instability
8
Q
fatal carbon monoxide poisoning levels
A
61-80%
9
Q
in a respiratory injury____________respirations will occur
A
increased
10
Q
A _____________sound at the site of injury would be noted with an open chest injury.
A
sucking
11
Q
Clinical manifestations of chronic obstructive pulmonary disease
A
hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced
Pulmonary function tests will demonstrate decreased vital capacity.
12
Q
What is vital capacity ?
A
the maximum amount of air a person can expel from the lungs after a maximum inhalation
patients with COPD will have decreased vital capacity
13
Q
What is the purpose of pursed lip breathing ?
A
To promote CO2 elimination
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation
14
Q
For tuberculosis patients, after___________- weeks of medication therapy, it is unlikely that the client will infect anyone.
A
2-3
15
Q
For tuberculosis patients, a sputum culture is needed every______________ weeks once medication therapy is initiated. When the results of _________sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.
A
2-4; 3
16
Q
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?
1.
Dry cough
2.
Hematuria
3.
Bronchospasm
4.
Blood-streaked sputum
A
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias
17
Q
What can be caused by proloned suctioning?
A
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
18
Q
Suctioning a client should be limited to ________seconds
A
10
The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
19
Q
During suctioning, the nurse should monitor the client closely for adverse effects, including _______________________. If adverse effects develop, especially cardiac irregularities, the procedure is ______________________
A
hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing
stopped and the client is reoxygenated.
20
Q
Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include
A
pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site.
21
Q
most distinctive sign of flail chest
A
paradoxical chest movement
22
Q
What is flail chest?
A
Flail chest results from multiple rib fractures. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
paradoxical chest movement - remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage.
23
Q
What is the earliest sign of acute respiratory distress syndrome?
A
Increased respiratory rate
can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
24
Q
The tuberculosis client is continued on medication therapy for up to _____months, depending on the situation. The client generally is considered noncontagious after _________weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of _________sputum cultures are negative.
A
12; 2 to 3; 3
25
Typical signs of pulmonary embolism
The most common initial symptom in pulmonary embolism is **chest pain that is sudden in onset**. The next most commonly reported symptom is **dyspnea**, which is accompanied by an **increased respiratory rate**. Other typical symptoms of pulmonary embolism include a**pprehension and restlessness, tachycardia, cough, and cyanosis.**
26
The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than \_\_\_\_\_\_\_\_\_\_\_mm
5
The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor
27
What do you know about histoplasmosis ?
Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.
Dyspnea is an expected finding
28
what do you know about sarcoidosis ?
this is a pulmonary disorder. there is a presence of epitheloid cell tubercles in the lung
assessment includes night sweats, cough, dyspnea, fever, weight loss, skin nodules, polyarthritis
Kveim test: Sarcoid node antigen is injected intradermally and causes a local nodular lesion in about 1 month
29
What do you know about silocosis ?
Silicosis results from **chronic, excessive inhalation of particles of free crystalline silica dust**.
The **client should wear a mask to limit inhalation of this substance**, which can cause restrictive lung disease after years of exposure.
30
The \_\_\_\_\_\_\_\_\_\_\_\_\_-mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration.
Venturi
31
Positions that will assist the client with emphysema with breathing include
sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.
32
Symptoms of Tuberculosis
**Fatigue, Lethargy, Anorexia, Weight Loss,** Low grade fever, chills, night sweats, persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood
chest tightness and a dull, aching **chest pain** may accompany the cough
33
Tuberculosis is definitively diagnosed through
culture and isolation of Mycobacterium tuberculosis.
A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
34
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority?
1.
Ensure that the client has been intubated.
2.
Set the defibrillator to the "synchronize" mode.
3.
Administer an amiodarone bolus intravenously.
4.
Confirm that the rhythm is actually ventricular fibrillation.
Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections.
Note the strategic word, priority. Focus on the subject, ventricular fibrillation. ***Note that the correct option directly addresses this subject and also addresses assessment of the client.***
35
The energy level used for all defibrillation attempts with a monophasic defibrillator is \_\_\_\_\_\_\_-joules.
360
36
The jaw thrust without the head tilt maneuver is used when ............
head or neck trauma is suspected.
This maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck
37
A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?
## Footnote
1.
Serous
2.
Bloody
3.
Serosanguineous
4.
Bloody, with frequent small clots
In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing
38
The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?
Deflate the cuff on the tube
Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. **This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. *When plugging a cuffed tracheostomy tube, the cuff must be deflated.*** If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place.
39
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are \_\_\_\_\_\_\_\_\_\_\_-clients
immobilized
Basic preventive measures include **early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression.** Keeping the client well hydrated is essential because dehydration predisposes to clotting.
A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.
40
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?
**Document the findings**
Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. **Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space.** Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected.
41
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?
***Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber***. **Intermittent (not constant) bubbling is normal**. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. ***Continuous bubbling during inspiration and expiration indicates that an air leak exists***. If this occurs, it must be corrected. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema.
42
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?
1.
Muscle weakness in the arms and legs
2.
A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C)
3.
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
4.
A heart rate of 80 beats/minute, decreased from 85 beats/minute
Complications of mechanical ventilation include the following: **hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart**; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean.
43
Regarding chest tubes
Does the presence of fluctuation of the fluid level in the water seal chamber indicate a patent drainage system?
YES !
With normal breathing, the water level rises with inspiration and falls with expiration. ***Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded.***
44
Regarding chest tubes
What would cause fluctuations within the water seal chamber to stop ?
Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded
45
How does the nurse immediately verify the placement of an ET tube ?
by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically.
46
Endotracheal tube placement
The nurse marks the ET tube at the point where it enters the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_for ongoing monitoring of correct placement
nose or mouth
47
.What should the nurse do initiatially before suctioning a client with a tracheostomy tube?
**The nurse should hyperoxygenate the client both before and after suctioning.** This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen
48
The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?
1.
Suctioning the client every hour
2.
Applying suction only during withdrawal of the catheter
3.
Hyperventilating the client with 100% oxygen before suctioning
4.
Applying suction intermittently during withdrawal of the catheter
The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal
49
The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?
The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the ties.
50
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action?
Once the client has been weaned successfullyand has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. **The ET tube is suctioned first, and then the cuff is deflated and the tube is removed.**
51
Causes of high-pressure ventilator alarms include
water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator
52
causes of low pressure ventilator alarms
**A disconnection or leak in the system** and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.
53
adverse effects of suctioning include
c**yanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions**.
***If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the health care provider.***
Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that he or she cannot tolerate the procedure.
54
TRUE OR FALSE
secretions may be blood tinged for a few days after tracheostomy insertion
TRUE
55
Impaired gas exchange could occur after tracheostomy because of
excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions.
56
\_\_\_\_\_\_\_\_\_\_\_\_\_\_measures oxygen saturation in blood flowing through the blood vessels in the periphery of the body and that inaccurate measurement may result from any factor that impairs \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
Pulse oximetry; blood flow through the periphery such as hypotension
57
When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as \_\_\_\_\_\_\_\_\_\_\_\_\_
tidaling
58
\_\_\_\_\_\_\_\_\_\_\_\_--of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia.
Strapping
59
The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?
A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis.
60
The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit
61
The client with TB may report signs and symptoms that have been present for
**weeks or even months**. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.
62
The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply.
## Footnote
1.
Keeping a supply of suction catheters at the bedside
2.
Auscultating breath sounds to determine the need for suctioning
3.
Hyperoxygenating the client before, during, and after suctioning
4.
Intermittently suctioning during insertion of the suction catheter
5.
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
**Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used**. *The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed.* The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. **Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted.** Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure.
63
he tuberculin skin test is an accurate and reliable test that will provide information to the health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result should be done \_\_\_\_\_\_\_\_\_\_\_\_-hours after the injection.
48-72
64
The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?
1.
Drink hot tea throughout the day.
2.
Drink hot cocoa instead of coffee.
3.
Restrict fluid intake to 1000 mL daily.
4.
Eat foods that are highly seasoned in moderation.
Foods that are highly seasoned are irritating to the throat and should be completely avoided. The client with pharyngitis should be instructed to **consume cool clear fluids, ice chips, or ice pops to soothe the painful throat.**
*Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production.*
**The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.**
65
A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?
Assist the client to a sitting position with the head tilted forward.
***The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes***.
Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication.
The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.
66
The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?
1.
"I need to protect the stoma from water."
2.
"Soaps should be avoided near the stoma."
3.
"I should use diluted alcohol on the stoma to clean it."
4.
"I should apply a non–oil-based ointment to the skin surrounding the stoma."
The client with a stoma should be instructed to wash the stoma daily with a washcloth. ***The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway.*** A non–oil-based ointment applied to the skin around the stoma helps to prevent cracking.
67
A \_\_\_\_\_\_\_\_\_\_\_--is an abnormal opening,
fistula
68
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
1.
Suctioning is required frequently.
2.
The client's skin and mucous membranes are light pink.
3.
Aspiration of gastric contents occurs during suctioning.
4.
Excessive secretions are suctioned from the tube and stoma.
Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents.
69
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?
Manually ventilate the client
## Footnote
**Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.**
70
If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should
manually ventilate the client with a resuscitation device. The nurse should never shut off the alarm.
71
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?
## Footnote
1.
Excessive secretions
2.
Kinks in the ventilator tubing
3.
The presence of a mucous plug
4.
Displacement of the endotracheal tube
The low-exhaled volume alarm **(low pressure alarm**) will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts.
72
A high-pressure alarm occurs if the amount of pressure needed for ventilating a client \_\_\_\_\_\_\_\_\_\_\_--the preset amount
exceeds
73
SIMV is one of the methods used for weaning. With this method, the \_\_\_\_\_\_\_\_\_\_\_\_is gradually decreased until the client assumes all of the work of breathing on his or her own.
respiratory rate
This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. **The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation**
74
This device requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the \_\_\_\_\_\_\_\_\_\_is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting.
The T-piece (or Briggs device)
75
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is the amount of air delivered with each set breath on the mechanical ventilator. A \_\_\_\_\_\_\_\_\_\_-is a breath that has a greater volume than the preset tidal volume.
Tidal Volume; sigh
76
Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. This disease cannot be transmitted from one person to another. TRUE OR FALSE
TRUE
77
A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.
1.
Monitor the client's temperature.
2.
Use sterile technique when suctioning.
3.
Use the closed-system method of suctioning.
4.
Monitor sputum characteristics and amounts.
Monitoring temperature and sputum production is indicated in the care of the client. **A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning.**
## Footnote
*Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.*
78
On removal of the chest tube, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive.
sterile petrolatum gauze and sterile 4 × 4 gauze
79
In most cases of ARDS, ___________ and __________ are the first clinical manifestations
tachypnea and dyspnea
. Blood-tinged frothy sputum would be a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear
80
Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling).
When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when...............
the lung has reexpanded or if the chest drainage tubes are kinked or obstructed.
81
Postoperative teaching following chest tube removal
When a chest tube is removed, an occlusive dressing, usually consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the health care provider says it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.
82
A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?
1.
Position the client in semi Fowler's position.
2.
Add water to the suction chamber as it evaporates.
3.
Instruct the client to avoid coughing and deep breathing.
4.
Tape the connection sites between the chest tube and the drainage system.
It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.
83
TRUE OR FALSE. The client with a chest tube should not deep breathe or cough.
FALSE
It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing.
84
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?
1.
Inflate the cuff on the tracheostomy tube.
2.
Deflate the cuff on the tracheostomy tube.
3.
Maintain the head of the bed in low Fowler's position.
4.
Place the tray in a comfortable position in front of the client.
Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. **A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used.** A noncuffed tube may be used when mechanical ventilation is not required. ***If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids***. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration.
NCLEX TEST STRATEGY
Note that the correct option and option 2 describe opposite actions; this indicates that one of these choices may be correct.
85
The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?
1.
"I should restrict my fluid intake for 2 weeks."
2.
"I should perform arm exercises 2 or 3 times a day."
3.
"If I experience any soreness in my chest or shoulder, I should notify the health care provider."
4.
"If I experience any numbness or altered sensation around the incision, I should contact the health care provider."
The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the health care provider if these symptoms occur.
86
Pain of pleuropulmonary (respiratory) origin usually worsens on \_\_\_\_\_\_\_\_\_\_\_\_.
inspiration
87
A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?
1.
Administration of plasma expanders, low-flow oxygen, and suctioning
2.
Administration of bronchodilators, intubation, and mechanical ventilation
3.
Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure
4.
Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask
**Respiratory failure is the most common cause of death after fat embolus.** The client **may be intubated and mechanically ventilated with positive end-expiratory pressure** to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema.
88
The high-pressure ventilator alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set \_\_\_\_\_\_\_\_\_\_\_\_\_\_-.
tidal volume
89
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?
1.
A disconnection of the ventilator tubing
2.
An exaggerated client inspiratory effort
3.
Accumulation of respiratory secretions
4.
Generation of extreme negative pressure by the client
**The high-pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume.** Causes include tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax.
90
The low-pressure ventilator alarm sounds when little or no __________ is generated during the delivery of the machine breaths.
pressure
Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure.
91
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?
## Footnote
1.
A tubing obstruction or kink
2.
The accumulation of secretions
3.
Disconnection of the ventilator tubing
4.
Condensation of water in the ventilator tubing
The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. **Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure.** The remaining options identify causes for triggering the high-pressure alarm.
92
When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate _____________ through the sense of smell.
appetite
93
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?
1.
"It will enter the left main bronchus if inserted too far."
2.
"It will enter the right main bronchus if inserted too far."
3.
"It may enter the left main bronchus if not inserted far enough."
4.
"It may enter the right main bronchus if not inserted far enough."
**If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus.** This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur.
94
A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose?
Humidifies the oxygen that is bypassing the client's nose
The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing
95
The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, **the nurse explains that which is the primary benefit?**
1.
Dilate the major bronchi.
2.
Increase surfactant production.
3.
Maintain inflation of the alveoli.
4.
Enhance ciliary action in the tracheobronchial tree.
**Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange**. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk.
96
The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas?
## Footnote
1.
Lobes
2.
Alveoli
3.
Trachea
4.
Main bronchi
**Postural drainage uses specific client positions that vary depending on the affected lobe or lobes**.
The positions usually place the head lower than the affected lung segments **to facilitate drainage of secretions**. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness.
97
The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be \_\_\_\_\_\_\_\_\_\_\_\_\_\_%.
88-92%
98
Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles\_\_\_\_\_\_\_\_\_\_\_. This allows air to flow upward out of the lungs. Air flows according to a \_\_\_\_\_\_\_\_\_\_\_gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.
relax; pressure
99
What is pleurisy ?
an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration.
100
The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider (HCP) states that as a result of fluid in the alveoli, surfactant production is falling. **What does the nurse anticipate as a physiological consequence?**
**Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs**. This prevents the alveoli from sticking together and collapsing at the end of exhalation.
When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis
101
When alveoli collapse, the lungs become "\_\_\_\_\_\_\_\_\_\_" because of decreased compliance
stiff
102
\_\_\_\_\_\_\_\_\_\_\_\_ occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated.
Shunting
103
The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?
## Footnote
1.
A shunt unit exists.
2.
Anatomical dead space is present.
3.
Physiological dead space is present.
4.
Ventilation-perfusion matching is occurring.
**When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists**. **As a result, no gas exchange occurs, and unoxgenated blood continues to circulate.** Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.
104
As the diaphragm contracts, it moves \_\_\_\_\_\_\_\_\_\_\_\_\_\_, becoming \_\_\_\_\_\_\_\_\_\_\_\_and expanding the thoracic cage, to promote lung expansion. This process occurs during the \_\_\_\_\_\_\_\_\_\_\_\_phase of the respiratory cycle.
downward and out; flatter; inspiratory
105
If an endotracheal tube is inserted past the carina, the tube will enter the\_\_\_\_\_\_\_\_\_\_\_\_\_-bronchus as a result of the natural curvature of the airway.
How can we detect incorrect tube placement ?
right main
This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because **only the right lung will have breath sounds and rise and fall with ventilation**
106
Room air contains \_\_\_\_% oxygen
21%
107
The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process?
1.
Osmosis
2.
Diffusion
3.
Ionization
4.
Active transport
***Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient***.
Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.
108
grossly bloody drainage indicates \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-
active bleeding or hemorrhage
109
Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains \_\_\_\_\_\_\_\_\_\_\_\_\_\_fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL.
serosanguineous
110
Can the nurse prescribe diagnosic tests ?
NO, the nurse **cannot** prescribe diagnostic tests,
111
The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?
1.
Contact the health care provider (HCP).
2.
Document the finding in the client's record.
3.
Call the employee health service department.
4.
Call the radiology department for a chest radiographic study to be done.
The nurse who obtains a positive test reading should call the HCP immediately. The HCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made.
112
chest tube assessment is done at least every ________ hours
8
113
A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented?
1.
The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift.
2.
The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record.
3.
The suction control chamber has sterile water added every shift, and the system is kept below waist level.
4.
The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.
***The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site.***
Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction.
***Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter.***
The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. **Sterile water is added to the suction control chamber only as needed to replace evaporation losses.**
114
What should be kept at the bedside of a client with a tracheostomy at all times ?
a replacement tube and an obturator, along with a curved hemostat, should be kept at the bedside of a client with a tracheostomy at all times.
115
The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action?
1.
Suction the client.
2.
Evaluate the cuff for a leak.
3.
Assess for a disconnection.
4.
Notify the respiratory therapist.
**When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction.** The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. A cuff leak and disconnection would cause the low-pressure alarm to sound, so options 2 and 3 can be eliminated. Notifying the respiratory therapist delays necessary treatment.
116
When the high-pressure alarm sounds on a ventilator, it is most likely because of an \_\_\_\_\_\_\_\_\_\_\_\_\_
obstruction.
The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning.
117
The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate?
DOCUMENT THE FINDINGS
With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.
118
Regarding chest tubes and the water seal chamber:
With normal breathing, the water level rises with inspiration and falls with expiration.
The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
positive-pressure mechanical ventilation.
119
Regarding chest tubes,
Constant bubbling occurring in the water seal chamber may indicate an\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ in the system
air leak
120
The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make?
1.
The client has no risk of acquiring TB and needs no further workup.
2.
The client is at increased risk for acquiring TB and needs immediate medication therapy.
3.
The client's test result will be negative, and a sputum culture will be required for diagnosis.
4.
The client's test result will be positive, and a chest x-ray study will be required for evaluation.
The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. **The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive**.
This client needs to be evaluated for TB with a chest radiographic study.
121
The \_\_\_\_\_\_\_\_\_vaccine contains attenuated tubercle bacilli and may be given to persons in foreign countries or persons traveling to foreign countries to produce increased resistance to tuberculosis
An individual who has received a BCG vaccine will have a _________ tuberculin skin test result and should be evaluated for tuberculosis with a \_\_\_\_\_\_\_\_\_\_\_\_
BCG; positive; chest x-ray
122
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_often is prescribed for pain and anxiety in the client receiving mechanical ventilation.
Morphine sulfate
123
A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?
1.
Ask a family member to stay with the client at all times.
2.
Ask the health care provider for a prescription for succinylcholine.
3.
Encourage the client to sleep until arterial blood gas results improve.
4.
Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.
**Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation**. **The nurse should speak to the client calmly and provide reassurance to the anxious client**.
Family members also are stressed, not just because of the complication but because of the original injury. ***It is not beneficial to ask the family to take on the burden of remaining with the client at all times.*** Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.
124
Typical signs and symptoms of pleural effusion include
**dry, nonproductive cough**; **dyspnea** (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment
dry cough
dyspnea
decreased tactile fremitus
dull percussion notes
125
This is a collection of pus within the pleural cavity.
Symptoms include
The client with **empyema** usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss.
There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.
126
After any procedure involving lung surgery, the nurse should position the client in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_position because it allows for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
semi Fowler's
This position allows for maximal lung expansion and promotes drainage through the chest tube that may be placed during surgery
127
Sim's position is also called and is used for
usually used for rectal examination, treatments, and enemas. It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. **It is also called lateral recumbent position**
128
After lung surgery the client needs to be upright for ease of breathing.
TRUE OR FALSE
TRUE
129
The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube?
***If the endotracheal tube is inserted too far, the tube will travel past the trachea and enter the right main bronchus.*** This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane
if the tube is not inserted far enough, no chest expansion will occur.
130
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance.
Thoracentesis
131
Elevations in body temperature cause a corresponding \_\_\_\_\_\_\_\_\_\_\_\_\_in respiratory rate. This occurs because the
increase; metabolic needs of the body increase with fever, requiring more oxygen.
132
With increased demand for oxygen, the body needs an increased supply.
TRUE OR FALSE
TRUE
133
The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing?
1.
Instruct the client to limit fluid intake.
2.
Place the client in low Fowler's position.
3.
Administer the prescribed bronchodilator.
4.
Place a continuous pulse oximeter on the client.
**Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea.**
The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.
134
As the diaphragm contracts it \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_This process occurs during the inspiratory phase of the respiratory cycle.
**moves downward and out, becoming flatter and expanding the thoracic cage.**
135
Obstruction of the upper airway can be due to obstruction by \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
edema, a tumor, or foreign body aspiration, or lymph node enlargement
136
The client with impending respiratory failure may need \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
intubation and mechanical ventilation.
137
The nurse would not suction a client without an inner cannula in place.
TRUE OR FALSE
TRUE
138
The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?
1.
Suction the client's airway.
2.
Wipe the inner cannula off with a clean washcloth.
3.
Dry the inner cannula thoroughly with sterile gauze.
4.
Allow the inner cannula to dry after washing it with sterile water.
After washing and rinsing the inner cannula with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. **The nurse would not suction a client without an inner cannula in place**. **This is a sterile procedure and therefore it is inaccurate to use a clean washcloth.**
**. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.**
139
Chronic sinusitis is characterized by
persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep.
140
anosmia
loss of smell
141
A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients?
## Footnote
1.
Get plenty of rest.
2.
Increase intake of liquids.
3.
Take antipyretics for fever.
4.
Get a flu shot immediately.
5.
Eat fruits and vegetables high in vitamin C.
Treatment for the flu includes **getting rest, drinking fluids, and taking in nutritious foods and beverages.** **Medications such as antipyretics and analgesics also may be used for symptom management**.
The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.
142
In the client with pleurisy, will the pleural friction rub heard upon auscultation dissapear?
Yes
Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. **Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears.**
143
Clients frequently at risk for pulmonary embolism include those who are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Others causes include those with conditions that are characterized by \_\_\_\_\_\_\_\_\_\_\_coagulabiltiy, _____________ disease, or _____________ age,
immobilized
This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.
144
The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?
## Footnote
1.
Cyanosis
2.
Hyperinflated chest
3.
Rapid, shallow respirations
4.
Coarse crackles auscultated bilaterally
Rapid, shallow respirations
**An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation.**
Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients.
A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.
145
Postprocedure care for a client who has had a thoracentesis
**After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion.** Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. **Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues**. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.
146
What to remember about subcutaneous emphysema ?
Subcutaneous emphysema (crepitus) may follow a thoracentesis because air in the pleural cavity leaks into subcutaneous tissues. ***The involved tissues feel like lumpy paper and crackle when palpated (crepitus***).
Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.
147
What do you know about Legionnaires disease?
Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. **Antibiotics must be given for the entire duration of the prescription;**
148
COPD is a term that represents the pathology and symptoms that occur with clients experiencing both ______________ and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
emphysema and chronic bronchitis
149
A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority?
1.
Low cardiac output secondary to cor pulmonale
2.
Gas exchange alteration related to ventilation-perfusion mismatch
3.
Altered breathing pattern secondary to increased work of breathing
4.
Inability to clear the airway related to inability to expectorate sputum
COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.
150
The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing?
## Footnote
1.
Sitting up and leaning on a table
2.
Standing and leaning against a wall
3.
Lying on the back in a low Fowler's position
4.
Sitting up with the elbows resting on the knees
T**he client should not lie on the back because this reduces movement of a large area of the client's chest wall**. The client should use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.
151
home care instructions to a client who had a laryngectomy and has a stoma?
The nurse should teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions **focus on protection of the stoma and the prevention of infection**.
Interventions include obtaining a MedicAlert bracelet, avoiding exposure to people with infections, avoiding swimming, using care when showering, and preventing debris from entering the stoma. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.
152
In the first few hours after surgery the drainage from the chest tube is \_\_\_\_\_\_\_\_\_\_\_\_\_\_. After several hours it becomes \_\_\_\_\_\_\_\_\_\_\_\_\_\_.
The client should not experience frequent clotting. ***Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.***
bloody; serosanguineous
153
patent chest tubes do not allow \_\_\_\_\_\_\_\_\_\_\_to collect in the pleural space
following thoracic surgery there may be considerable capillary oozing for some hours in the postoperative period
TRUE OR FALSE
blood; TRUE
154
Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Continuous bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space.
TRUE OR FALSE
FALSE
Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. **Intermittent bubbling is normal.** It indicates that the system is accomplishing one of its purposes, removing air from the pleural space.
155
The nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer?
1. Cough
2. Hoarseness
3. Hemoptysis
4. Pleuritic pain
**Cough is the most frequent early symptom of lung cancer,** which begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. **Hoarseness indicates that the affected tissue is in the upper airway.**
**Wheezing and blood-streaked sputum (hemoptysis) are later signs of lung cancer**. ***Pain is a very late sign*** and is usually pleuritic in nature.
To discriminate between cough and hoarseness, think about location. ***Hoarseness would indicate that the affected tissue is in the upper airway, whereas cough would indicate lower airway.*** Because the question is asking about lung cancer, which is lower airway, the answer must be cough.
156
The earliest clinical sign of ARDS is an \_\_\_\_\_\_\_\_\_respiratory rate.
increased
***Breathing becomes labored***, and the client may exhibit air hunger, retractions, and cyanosis. ***Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.***
157
\_\_\_\_\_\_\_\_\_\_\_\_\_\_is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli leading to \_\_\_\_\_\_\_\_\_\_\_\_. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.
Silicosis; fibrosis
158
Silicosis is restricted to the _____________ system only. There is evidence of _____________ on chest x-ray. Pulmonary function studies reveal some decreases in \_\_\_\_\_\_\_\_\_\_\_capacity and total lung \_\_\_\_\_\_\_\_\_
**respiratory**
The client with silicosis has evidence of **fibrosis** on chest x-ray. Pulmonary function studies reveal some decreases in **vital capacity and total lung volume.**
159
The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result?
NEGATIVE
A positive reading has an induration measuring 10 mm or larger and is considered abnormal.
A small area of ecchymosis is insignificant and probably is related to injection technique
160
The common clinical manifestations of pulmonary embolism are
tachypnea, tachycardia, dyspnea, and chest pain.
161
The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate?
1.
Increase to 3 L/min and titrate until the SpO2 is 95%.
2.
Increase to 3 L/min and titrate until the SpO2 is 88%.
3.
Place the client on a nonrebreather mask on 100% FiO2.
4.
Maintain at 2 L/min and call respiratory therapy for a breathing treatment.
Oxygen is used cautiously and should be titrated to the lowest amount needed;
however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and **the current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%.** An SpO2 of 95% is the recommended level for a healthy individual; therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect
162
Who are those at high risk for acquiring tuberculosis ?
Clients at high risk for acquiring tuberculosis include **immigrants from Asia, Africa, Latin America, and Oceania**; medically underserved populations (ethnic minorities, homeless); **those with human immunodeficiency virus infection or other immunosuppressive disorders**; **residents in group settings** (long-term care, correctional facilities); and health care workers.
163
The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction?
Rationale
Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; **food and drink should be avoided 15 minutes before or during use.**
164
High-pressure ventilator alarms can be triggered by \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, such as occurs with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing.
**increased airway resistance**
165
The low-pressure ventilator alarm can be caused by
disconnected tubing, ETT cuff leak, or apnea
166
High-pressure alarms can be triggered by increased\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
airway resistance
excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing are all causes of high pressure alarms
167
The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?
1.
Tidaling is absent.
2.
Gentle bubbling is observed in the suction control chamber.
3.
Vacillation of water in the water seal chamber occurs during respiration.
4.
Continuous bubbling is observed in the water seal chamber during inspiration and expiration.
Continuous bubbling is observed in the water seal chamber during inspiration and expiration.
**Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity**.
Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of reexpansion of the lung or obstruction or kinking of the chest tube.
168
Absence of tidaling within the water seal chamber of the chest tube can be indicative of
reexpansion of the lung or obstruction or kinking of the chest tube.
169
Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system?
## Footnote
1.
Empty the drainage collection chamber every shift.
2.
Ensure the water level in the water seal chamber is at the 2-cm level.
3.
Maintain the drainage collection device at the level of the client's chest.
4.
Clamp the chest tube before moving the client from the bed to the chair.
**The water seal chamber acts as a 1-way valve. It allows air and fluid to leave the pleural space but prevents reentry of atmospheric air. The minimum amount needed is 2 cm of water**. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. A chest tube should not be clamped unless specifically prescribed.
170
The water seal chamber acts as a \_\_\_\_\_\_\_\_\_\_valve. It allows air and fluid to leave the pleural space but prevents reentry of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. The minimum amount needed is 2 cm of water
1-way; atmospheric air
171
The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?
1.
Rhonchi are auscultated.
2.
Pleural friction rub is heard.
3.
Fine crackles are auscultated.
4.
Pulse oximetry reading is 96%.
Presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli.
172
Fine crackles are indicative of air moving into \_\_\_\_\_\_\_\_\_\_\_\_\_\_--
previously deflated alveoli.
173
Presence of rhonchi is an indication that there are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. The client requires suctioning if the client cannot expectorate them.
secretions in the large airways
174
The nurse should anticipate that a client with a lobectomy will have a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_and will need \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_at the bedside for emergency use. The nurse would not need a code cart at the bedside unless the client was in cardiac arrest.
chest tube; suction, Vaseline gauze, and a clamp
175
NCLEX strategy: watch out for closed ended words "all" & "only"
you are going to be a great nurse
176
The best source of information is the client.
TRUE OR FALSE
TRUE
177
A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?
## Footnote
1.
Focus only on the physical examination.
2.
Obtain all information from family members.
3.
Use the health care provider's medical history.
4.
Plan short sessions with the client to obtain data.
The best source of information is the client. Option 1 is incorrect; ***the physical examination is not part of the health history***. Option 2 is incorrect because it refers to all information. Option 3 is incorrect because the ***health care provider's medical history provides data that are different from the nurse's assessment***.
## Footnote
**All efforts should be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.**
178
Which nursing interventions are appropriate in caring for a client with emphysema?
Think about fluids, positioning, physiotherapy, activity, and breathing techniques
***Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration.***
**Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea.**
* **The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between.**
****Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.
179
Chest physiotherapy consists of\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ These techniques are helpful in removing secretions.
percussion, vibration, and postural drainage.
180
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply.
1.
Dyspnea at rest
2.
Clubbed fingers
3.
Muscle retractions
4.
Decreased respiratory rate
5.
Increased body temperature
6.
Prolonged expiratory breathing phase
The client with COPD who is eligible for a lung transplantation **has end-stage COPD** and will have clinical manifestations of **hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide.**
Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.
181
Lying supine will enhance breathing.
TRUE OR FALSE
FALSE
Lying supine will **worsen** breathing.
182
Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?
1.
Sitting position
2.
Tripod position
3.
Supine position
4.
High Fowler's position
The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. **Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity.** The sitting position and high Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.
183
How does the Tripod position decrease the work of breathing in patients with COPD ?
The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. **Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity.**
184
A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first?
## Footnote
1.
Call respiratory therapy.
2.
Contact the health care provider.
3.
Check the client's blood pressure.
4.
Suction the client through the endotracheal tube.
The client is choking on their secretions
**The client is choking on secretions, which should be removed by suctioning of the endotracheal tube.** There is no need at this time to contact the health care provider or call for respiratory therapy. The nurse should check the client's blood pressure, but **suctioning is the priority.**
185
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation?
## Footnote
1.
There is a leak in the system.
2.
The chest tube is functioning as expected.
3.
The amount of suction needs to be decreased.
4.
The occlusive dressing at the insertion site needs reinforcement.
The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. **Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded.**
Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. **Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased**. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water seal chamber.
186
When does fluctuation within the water seal chamber of a chest tube stop ?
What would excessive and vigorous bubbling in the suction control chamber indicate /
Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded.
Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased
187
The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly?
## Footnote
1.
The client breathes in through the mouth.
2.
The client breathes out slowly through the mouth.
3.
The client avoids using the abdominal muscles to breathe out.
4.
The client puffs out the cheeks when breathing out through the mouth.
Pursed-lip breathing **facilitates maximal expiration** **for clients with obstructive lung disease**. The client should close the mouth and breathe in through the nose. **The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks.** The client should spend at least twice the amount of time breathing out that it took to breathe in. **The client should use the abdominal muscles to assist in squeezing out all of the air.**
The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.
188
Dyspnea and chest pain occur late in the disease process of tuberculosis
TRUE OR FALSE
TRUE
189
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is the result of replacement of air in the alveoli by transudate, pus, blood, cells or other substances. \_\_\_\_\_\_\_\_\_\_\_\_\_\_is by far the most common cause of consolidation.
Consolidation; Pneumonia
190
auscultation over areas of consolidation of lung tissue will reveal ________________ breath sounds.
bronchial
191
Bronchial breath sounds are \_\_\_\_\_\_\_\_\_\_\_\_\_\_-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and \_\_\_\_\_\_\_\_\_\_-than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the \_\_\_\_\_\_\_\_\_\_\_\_and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_of lung tissue, as in a lung mass, atelectasis, or pneumonia. y.
loud, high; longer; trachea; consolidation
192
A \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is not cleared by a cough.
What does it sound like? What are its characterisitcs ?
pleural friction rub
It is a superficial, low-pitched, coarse rubbing or grating sound that sounds like 2 rough surfaces rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface.
193
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--occur with sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough.
Crackles
194
Disorders that cause \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-, such as emphysema or asthma, would produce high- or low-pitched wheezes (musical sounds similar to a squeak).
airflow obstruction
195
These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema
WHEEZES
196
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. What would the nurse do if this was heard?
**Stridor**
The nurse immediately notifies the health care provider (HCP). The nurse also places the client in a high Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy
197
Crackles are audible when there is a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-, are usually heard during inspiration, and do not clear with a cough.
sudden opening of small airways that contain fluid
Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema.
198
Passage of air through a narrowed airway is associated with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(a high-pitched musical sound similar to a squeak).
wheezes
199
Signs and symptoms of head and mouth cancer
Signs and symptoms of head and neck cancers include pain; **lump in the mouth, throat, or neck**; **difficulty swallowing;** color changes in the mouth or tongue to red, white, gray, dark brown, or black; **oral lesion or sore that does not heal in 2 weeks;** persistent or unexplained oral bleeding; numbness of the mouth, lips, or face; change in the fit of dentures; **burning sensation when drinking citrus juices or hot liquids**; persistent, unilateral ear pain; hoarseness or change in voice quality; persistent or recurrent sore throat; shortness of breath; and anorexia and weight loss.
200
Sustained inhalation helps maintain \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-of terminal bronchioles and alveoli, thereby promoting better\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk.
inflation; gas exchange
201
Triggers for asthma include
response to the presence of **specific allergens;** general irritants such as **cold air, dry air, or fine airborne particles;** microorganisms; and **aspirin and other NSAIDs**.
Increased airway sensitivity (hyperresponsiveness) can occur with **exercise, with an upper respiratory illness,** and for unknown reasons.
Clean air and adequate rest and sleep help to promote lung function.
202
What is the importance of surfactant ?
Surfactant is a phospholipid produced in the lungs that **decreases surface tension in the lungs**. This **prevents the alveoli from sticking together and collapsing at the end of exhalation**.
**When alveoli collapse, the lungs become "stiff" because of decreased compliance.** Common causes of decreased surfactant production are ARDS and atelectasis. Viral infection may be one reason a client develops atelectasis.
203
What happens when alveoli collapse?
When alveoli collapse, the lungs become "stiff" because of decreased compliance.
204
A client with COPD will exist in a state of respiratory \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2.
acidosis
205
The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply.
1.
The dry suction control regulation set to the prescribed amount
2.
The water filled suction control chamber filled to the prescribed amount
3.
Increased intermittent bubbling in the water seal chamber when the system is to gravity
4.
Continuous bubbling in the water seal chamber when the system is connected to suction
5.
The drainage in the collection chamber marked each shift to monitor the amount of drainage
There are 2 types of chest drainage systems: **the wet drainage system and the dry drainage system**. On routine assessment of the system, the nurse should look at the different chambers. **For a dry drainage system, the nurse should check the dry suction control regulation and make sure it is set to the prescribed amount. The nurse should also look for the orange floater ball to appear in the window; this indicates that the suction is being applied correctly.**
Tidaling should be noted in the water seal chamber. The nurse should also check the water seal chamber; **if the system is connected to suction (as opposed to gravity), tidaling may not be seen and the suction should be turned off to check for tidaling.**
If continuous bubbling is noted or the bubbling increases, an air leak may be present and the connections should be checked. In a dry drainage system, water is not added to the suction control chamber; this is done with a wet drainage system. The drainage collection chamber should be monitored and marked each shift to monitor the amount of drainage, if any.
206
The nurse should determine that tracheal suctioning is needed if which is noted?
1.
Arterial oxygen level of 90 mm Hg
2.
2 hours elapsed since the last suctioning
3.
Congested breath sounds in the lung fields
4.
Respiratory rate of 18 breaths/min, up from 16 breaths/min
Suctioning is i**ndicated only when the client has adventitious breath sounds or has accumulation of secretions**. It is not performed routinely according to time elapsed since the last suctioning (2 hours elapsed since the last suctioning). Arterial blood gas results and respiratory rate (arterial oxygen level of 90 mm Hg and respiratory rate of 18 breaths/min, up from 16 breaths/min) are **not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.**
207
Suctioning is indicated only when the client has \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
adventitious breath sounds or has accumulation of secretions
208
Suctioning is done on a routine basis
TRUE OR FALSE
FALSE
It is done as needed based on the presence of adventitious breath sounds and the accumulation of secretions
209
The clinical manifestations of COPD are several, including \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Chest x-ray results indicate a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_chest and may indicate a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_diaphragm if the disease is advanced.
hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation
hyperinflated chest; flattened diaphragm
210
Sitting up and leaning on a table
Standing and leaning against a wall
Sitting up with elbows resting on knees
All these positions do what ?
These allow for ***maximal chest expansion and decreased use of accessory muscles of respiration.***
**The client should not lie on the back because it reduces movement of a large area of the client's chest wall.**
**Sitting is better than standing,** whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.
211
The presence of fluctuation of the fluid level in the water seal chamber indicates a \_\_\_\_\_\_\_\_\_\_\_\_\_\_drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the
patent; tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded.
212
What instructions should be given to the client upon removal of a chest tube?
***When the chest tube is removed, the client is asked to take a deep breath and hold it.***
The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seal themselves off, and the wound heals in less than 1 week.
213
the primary danger after removal of an artificial airway is the client's ability to maintain a
patent airway and breathe independently
214
a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction.
STRIDOR
The nurse reports the presence of stridor to the HCP immediately.
215
The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding?
1.
The drainage chamber is full.
2.
The pneumothorax is resolving.
3.
The suction chamber system is shut off.
4.
There is an air leak somewhere in the system.
Continuous bubbling through both inspiration and expiration indicates that **there is air leaking into the system**. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. **Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.**
216
Instructions for using an incentive spirometer
Sit upright in the bed or chair
## Footnote
Place the mouthpiece in your mouth and seal your lips tightly around it.
After maximum inspiration, hold the breath for 2 to 3 seconds and exhale through pursed lips
217
Risk factors for COPD include
cigarette smoking, environmental factors, genetics, and AAT deficiency.
irritants to the lungs can worsen this condition. Also, recall that COPD has a genetic component.
218
Determining _____________________ is the first assessment to make in an emergency.
unresponsiveness
Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output.
219
The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first?
1.
Heart rate
2.
Blood pressure
3.
Respiratory rate
4.
Check responsiveness
VT is associated with a significant decrease in cardiac output. **Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output**. Therefore, the first action is to determine responsiveness of the client. Then the nurse should check the client's pulse to determine the next treatment strategy.
220
What is the correct placement of pads for defibrillation?
To the right of the sternum and to the left of the precordium
The nurse would place 1 gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads.
The anterior-apex placement works well for defibrillation and cardioversion, as well as for monitoring an electrocardiogram. In this placement, the anterior pad is placed on the right, below the clavicle. The other is applied to the left side of the client, just below and to the left of the pectoral muscle.
221
An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action?
1.
The ratio of compressions to ventilations is 30:2.
2.
The carotid pulse is palpable with each compression.
3.
Respirations are given at a rate of 10 breaths per minute.
4.
The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).
**With effective compressions, carotid pulsations should be present.** At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. **Assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR.** Correct procedure for CPR in an adult includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of at least 2 inches (5 cm). The 30:2 compression-to-ventilation ratio yields an effective rate of 10 breaths per minute.
222
What is the most accurate way to assess the effectiveness of CPR ?
With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital.
## Footnote
**Assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR.**
223
When performing CPR on adults, the ratio of chest compressions to breaths should be \_\_\_\_\_\_\_\_\_\_\_\_-for both 1-rescuer and 2-rescuer CPR.
30:2
The ratio of 15:2 is used for children and infants during 2-rescuer CPR.
224
when CPR is performed on infants, the sternum should be depressed at least one third the depth of chest, which is about\_\_\_\_\_\_\_\_\_\_ inches or 4 cm
1½
225
The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure?
1.
Radial artery
2.
Carotid artery
3.
Brachial artery
4.
Popliteal artery
To assess a pulse in an infant (younger than 1 year), the pulse is checked at the brachial or femoral artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant
226
The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that **which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus?**
Maintain manual left uterine displacement during compressions.
Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression. If the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compressions.
227
The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions?
On the lower half of the sternum
Chest locations are found by placing the hands on the lower half of the sternum. To locate this area, find the notch where the rib margin meets the sternum, and place the middle finger on this notch and the index finger next to it. Next, place the heel of the opposite hand on the lower half of the sternum, close to the index finger. Remove the first hand, place it on top of the hand on the sternum, and begin chest compressions.
228
Whenever a neck injury is suspected, the \_\_\_\_\_\_\_\_\_\_\_\_\_\_maneuver should be used during basic life support (BLS) to open the airway.
jaw thrust
The head tilt–chin lift produces hyperextension of the neck and could cause complications if a neck injury is present.
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The nurse notes that a 14-year-old child is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The child becomes unconscious. What procedure should the nurse perform next?
1.
Perform a finger sweep.
2.
Start chest compressions.
3.
Attempt rescue breathing.
4.
Ask the parent what happened.
START CHEST COMPRESSIONS
To perform the abdominal thrust maneuver for a conscious child, the rescuer stands or kneels behind the child and places the arms directly under the child's axillae and then around the child. The thumb side of 1 fist is placed against the child's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered. If the child becomes unconscious, the nurse should start cardiopulmonary resuscitation, first beginning compressions. Performing a blind finger sweep is not recommended. If the object can be visualized and is retrievable, it is acceptable to attempt to remove the object. Rescue breathing is not appropriate at this time but may be necessary later. It will be necessary at some point to determine what happened, but this would not be the nurse's next action.
Also, recalling the CAB procedure–compressions–airway–breathing–will assist you in answering correctly.
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How would you perform the abdominal thrust maneuver for a child ?
To perform the abdominal thrust maneuver for a conscious child, the rescuer stands or kneels behind the child and places the arms directly under the child's axillae and then around the child. The thumb side of 1 fist is placed against the child's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered. If the child becomes unconscious, the nurse should start cardiopulmonary resuscitation, first beginning compressions
231
The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help?
1.
Check for carotid pulse.
2.
Call anesthesia for intubation.
3.
Begin rescue breathing with head tilt–chin lift.
4.
Perform compressions at 100 to 120 times per minute.
After pressing the emergency response button in the room, the nurse should begin cardiopulmonary resuscitation (CPR) on the infant, starting with chest compressions. The rate of chest compressions is 100 to 120 times per minute. The brachial pulse is assessed on infants; the carotid pulse is difficult to palpate due to their short, thick necks. When a cardiopulmonary arrest alert is called, an experienced staff member with intubation skills is usually included on the response team. Compressions are started before rescue breathing.
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The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point?
When assessing a pulse in an infant (younger than 1 year), **the pulse should be checked at the brachial artery.**
This is because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult.
233
External public access defibrillator (PAD) interprets that the rhythm of a pulseless victim is ventricular fibrillation and advises defibrillation. Which action should the rescuer take next?
Order people away from the client, charge the machine, and depress the discharge buttons.
If the victim is in ventricular fibrillation, defibrillation is necessary. If the PAD advises to defibrillate, the rescuer orders all people away from the client, charges the machine, and pushes both of the discharge buttons on the console at the same time. The charge is delivered through the patch electrodes, so this method is known as "hands off" defibrillation, which is safer for the rescuer. The sequence of charges is similar to that of conventional defibrillation.
234
Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next?
1.
Defibrillate 1 more time, and then terminate the resuscitation effort.
2.
Administer a bolus of fluid intravenously, and resume defibrillation attempts.
3.
Perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable.
4.
Perform CPR for 1 minute, assess, and then defibrillate up to 3 more times.
If a client is unconscious and has no pulse, the nurse would shout for help (activate emergency response) and immediately initiate CPR. If the rhythm is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This pattern is repeated 2 more times if the rhythm remains shockable. Treatment with medications is also done during this time to reverse the cause of the ventricular fibrillation.
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If a client is unconscious and has no pulse, the nurse would \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
shout for help (activate emergency response) and immediately initiate CPR.
If the rhythm is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This pattern is repeated 2 more times if the rhythm remains shockable. Treatment with medications is also done during this time to reverse the cause of the ventricular fibrillation.
236
The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next?
F**or witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom a defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use.**
After completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. Defibrillation may be warranted depending on the assessed rhythm. Epinephrine may be prepared depending on the rhythm, but this would be prescribed by a health care provider (HCP). Chest compressions should not be interrupted for more than 10 seconds.
237
For health care providers (HCPs) such as the nurse, the sequence for removing a foreign body airway obstruction in an adult is as follows.
After determining unconsciousness, the airway is opened and the rescuer looks into the mouth of the victim and removes the object blocking the airway, if it is seen. Next, the HCP attempts to ventilate the victim. If unsuccessful, the victim's head is repositioned and ventilation is reattempted. Five abdominal thrusts are then delivered. The sequence is repeated until successful.
238
The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed?
1.
"I need to avoid alcohol and sedative medications."
2.
"I have to cut down on the percentage of carbohydrates in my diet."
3.
"Besides smoking, I can't be around second- or thirdhand smoke."
4.
"I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."
Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide–sensitive chemoreceptors are essentially not functioning. **Their stimulus to breathe is a decreased arterial oxygen** (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, **oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per health care provider prescription)**.
Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet.
**Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale**.
In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems.
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