Respiratory System

Question 1

Fever can cause dehydration because of excessive fluid loss due to

Answer 1

diaphoresis. Increased temperature also increases metabolism and the demand for O2

Question 2

What clients are at risk for pneumonia?

Answer 2

• Altered level of consciousness
• Depressed or absent gag and cough reflexes
• Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals
• Brain injury
• Drug overdose
• Stroke victims
• Immunocompromised

Question 3

Bronchial breath sounds are heard over

Answer 3

areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue

Question 4

What does hydration due?

Answer 4

1) Thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration
2) Is essential for client experiencing fever
3) Is important because 300-400mL of fluid is lost daily by the lungs through evaporation

Question 5

Irritability and restlessness are early signs of

Answer 5

Cerebral hypoxia

Question 6

Exposure of tobacco smoke is the primary cause of

Answer 6

COPD

Question 7

What is a pink puffer

Answer 7

Barrel chest in indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the tissues.

Question 8

What is a blue bloater?

Answer 8

Insufficient oxygenation occurs with chronic bronchitis and lead to generalized cyanosis and often right sided heart failure/ cor pulmonale

Question 9

If breath sounds are clear but the client is cyanotic and lethargic,

Answer 9

adequate oxygenation is not occurring

Question 10

With cancer of the larynx, the tongue and mouth appear

Answer 10

white, gray, dark brown, or black and appear patchy

Question 11

Tracheostomy care involves

Answer 11

cleaning the inner cannula, suctioning, and applying clean dressings.

Question 12

The difference between a laryngectomy tube and tracheostomy tube

Answer 12

Laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks in the first 24 hours

Question 13

glottal stop technique for fear of choking in laryngectomy clients.

Answer 13

Take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube.

Question 14

Rifampin

Answer 14

Reduced effectiveness of oral contraceptives; client should use other birth control methods during treatment. Gives body fluids orange tinge, stains soft contact lenses.

Question 15

Isoniazid, INH

Answer 15

Increased phenytoin, Dilantin, levels

Question 16

Ethambutol

Answer 16

Vision check before starting therapy and monthly there after. May have to take for 1-2 years

Question 17

Some tumors are so large that they fill entire lobes of the lung. When removed large spaces are left. Chest tubes

Answer 17

are not usually used with these clients because it is helpful if the mediastinal cavity where the lung used to be fills up with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space.

Question 18

Occlusive dressing prevents

Answer 18

A tension pneumothorax

Question 19

List four common symptoms of pneumonia the nurse might note on a physical exam?

Answer 19

Tachypnea
Fever with chills
Productive cough
Bronchial breath sounds

Question 20

State four nursing interventions for assisting the client to cough productively

Answer 20

• Encourage to deep breath
• Increased fluid intake to 3L/day
• Use humidity to loosen secretions
• Suction airway to stimulate coughing

Question 21

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

Answer 21

• Confusion
• Lethargy
• Anorexia
• Rapid Respiration Rate

Question 22

How dose the nurse prevent hypoxia during suctioning/?

Answer 22

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

Question 23

During mechanical ventilation, What are three major nursing interventions?

Answer 23

• Monitor clients respiratory status and secure connections
• Establish a communication mechanism with the client
• Keep airway clean with coughing and suctioning

Question 24

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

Answer 24

• Barrel Chest
• dry or productive cough
• Decreased breath sounds
• Dyspnea
• Crackles in lung field
• Works really hard to breathe

Question 25

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

Answer 25

Smoking

Question 26

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

Answer 26

• Involve the family and client in manipulation of the tracheostomy equipment before surgery
• Establish a communication mechanism
• Refer to a speech therapist
• Discuss rehabilitation programs

Question 27

List 5 nursing intervention after chest tube insertion?

Answer 27

• Maintain a dry occlusive dressing
• Keep all tubing connections tight and taped
• Monitor clients clinical status
• Encourage client to take deep breaths
• Monitor fluid drainage; mark time and fluid level

Question 28

What immediate action should the nurse take when a chest tube becomes disconnected?

Answer 28

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

Question 29

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

Answer 29

• Do not wash off lines
• Wear soft cotton garments
• Avoid the use of powders/creams on radiation sites

Question 30

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

Answer 30

• A mask for anyone entering room
• Private room
• A mask for client if they leave their room

Question 31

List four components of teaching for a client with TB

Answer 31

• Cough into tissues and dispose immediately in special bags
• Long term need for daily medications
• Good handwashing
• Report symptoms of deterioration such as blood in secretions