Respiratory System

Question 1

List four common symptoms of pneumonia the nurse might note on physical examination.

Answer 1

1. tachypnea
2. fever with chills
3. productive cough
4. bronchial breath sounds

Question 2

State four nursing interventions for assisting the client to cough productively.

Answer 2

1. encourage deep breathing
2. increase fluid intake to 3 L/day
3. use humidity to loosen secretions
4. suction airway to stimulate coughing

Question 3

What symptoms of pneumonia might the nurse expect to see in an older client?

Answer 3

Confusion, lethargy, anorexia, rapid respiratory rate

Question 4

How does the nurse prevent hypoxia during suctioning?

Answer 4

Deliver 100% O2 (hyperinflating) before and after each endotracheal suctioning.

Question 5

During mechanical ventilation, what are three major nursing interventions?

Answer 5

1. monitor clients respiratory status and secure connections
2. establish a communication mechanism with the client
3. keep airway clear by coughing and suctioning

Question 6

When examining a client with emphysema, what physical findings is the nurse likely to see?

Answer 6

Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields

Question 7

What is the most common risk factor associated with lung cancer?

Answer 7

Smoking

Question 8

Describe the preoperative nursing care for a client undergoing a laryngectomy.

Answer 8

• Involve family and client in manipulation of tracheostomy equipment before surgery.
• Plan acceptable communication methods.
• Refer to speech pathologist.
• Discuss rehabilitation program.

Question 9

List five nursing interventions after chest tube insertion.

Answer 9

1. Maintain a dry occlusive dressing on chest tube.
2. Keep all tubing connections tight and taped.
3. Monitor clients clinical status.
4. Encourage the client to breathe deeply periodically.
5. Monitor the fluid drainage, and mark the time of measurement and the fluid level.

Question 10

What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client?

Answer 10

• Place the end of the tube in a sterile water container at a 2-cm level.
• Apply an occlusive dressing, and notify health care provider stat.

Question 11

What instructions should be given to a client following radiation therapy?

Answer 11

Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiation site.

Question 12

What precautions are required for clients with TB when placed on respiratory isolation?

Answer 12

• a mask for anyone entering room
• private room
• client must wear mask if leaving room

Question 13

List four components of teaching for the client with tuberculosis.

Answer 13

1. Cough into tissues and dispose of immediately in special bags
2. Long-term need for daily medication
3. Good handwashing technique
4. Report symptoms of deterioration, e.g., blood in secretions