UNIT H-Clients with complex respiratory problems Flashcards
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and
identifies that the client has a 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a. Tell the client that he or she needs to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and marijuana
use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.
ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider
immediately.
d. Client’s respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.
ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by
decreased or absent breath sounds. The primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. If the
client’s heart rate is 55 beats/min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the
oxygen flow rate.
A nurse assesses a client’s respiratory status. Which information is most important for the nurse to obtain? a. Average daily fluid intake. b. Neck circumference. c. Height and weight. d. Occupation and hobbies.
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in
a client’s occupation and hobbies. Although it will be important for the nurse to assess the
client’s fluid intake, height, and weight, these will not be as important as determining his
occupation and hobbies. This is part of the I-PREPARE assessment model for particulate
matter exposure. Determining the client’s neck circumference will not be an important part of
a respiratory assessment.
A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral
chest diameter. Which question would the nurse ask the client in response to this finding?
a. “Are you taking any medications or herbal supplements?”
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”
ANS: B
The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral
(side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches
the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem,
such as chronic emphysema. It can also be seen in people who have lived at a high altitude for
many years. Medications, herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client to irritants that can cause
chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first.
A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds
are absent. While another nurse calls the Rapid Response Team, what action by the nurse
takes is most important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication
after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry
reading and perform other respiratory assessments. Temperature is not a priority. The nurse
can ask about other symptoms while conducting the assessment. The nurse would assess the
biopsy site and/or dressings, but this is not the first action.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention
would the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The
nurse would ensure signed informed consent has been obtained. Verifying that the client
understands complications and explaining the procedure to be performed will be done by the
primary health care provider, not the nurse. Measurement of oxygen saturation before and
after a 12-minute walk is not a procedure unique to a thoracentesis.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate
action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck.
ANS: D
A shift of central thoracic structures toward one side is a sign of a tension pneumothorax,
which is a medical emergency. The other findings are normal or near normal. The nurse
would report this finding immediately or call the Rapid Response Team.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of
water. What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the client’s gag reflex.
Before allowing the client anything to eat or drink, the nurse must check for the return of this
reflex.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times
when climbing a flight of stairs. Which intervention would the nurse include in this client’s
plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning
ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs
without pausing has class IV dyspnea. The nurse would provide assistance with activities of
daily living. These clients would be encouraged to participate in activities as tolerated. They
would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only
need oxygen if hypoxia is present.
A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement
would the nurse include in this client’s teaching?
a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
d. “Stopping this medication suddenly increases your risk for a heart attack.”
ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of
stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The
nurse would encourage the client to make a list of reasons for stopping the habit but would not
phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement
therapy. Stopping suddenly does not increase the risk of heart attack.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
The client presents with continuous cyanosis even with oxygen therapy. What action would
the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.
ANS:B
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an
adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify
the Rapid Response Team to provide advanced care. An albuterol treatment would not address
the client’s oxygenation problem. Assessment of pulses and cultures will not provide data
necessary to treat the client.
A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action
would the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
finding over the trachea and larynx. The nurse would document this finding. There is no need
to implement oxygen therapy, administer albuterol, or change the client’s position because the
finding is normal.
A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine
ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and
hallucinations. The nurse would assess for changes in behavior and thought processes,
including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and
orange-colored urine are not adverse effects of this medication. Decreased cravings are a
therapeutic response to this medication.
While obtaining a client’s health history, the client states, “I am allergic to avocados, molds,
and grass.” Which responses by the nurse are best? (Select all that apply.)
a. “What happens when you are exposed to those things?
b. “How do you treat these allergies?”
c. “When was the last time you ate foods containing avocados?”
d. “I will document this in your record so all so everyone knows.”
e. “Have you ever been in the hospital after an allergic response?”
f. “How do manage to avoid grass and mold?”
ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response
to treatment. The nurse would also document the allergies in a prominent place in the client’s
medical record. Asking about the last time the client ate avocados does not provide any
pertinent information for the client’s plan of care. Asking how a client manages to avoid
environmental allergies in this fashion also does not provide any pertinent information.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
for a client. Which statements would the nurse include in communications with the respiratory
therapist prior to the tests? (Select all that apply.)
a. “I held the client’s morning bronchodilator medication.”
b. “The client is ready to go down to radiology for this examination.”
c. “Physical therapy states the client can run on a treadmill.”
d. “I advised the client not to smoke for 6 hours prior to the test.”
e. “The client is alert and can follow your commands.”
ANS: A, D, E
To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have
been administered in the past 4 to 6 hours (depending on the suspected cause), the client did
not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands,
including different breathing maneuvers. The respiratory therapist can perform PFTs at the
bedside or the respiratory lab. A treadmill is not used for this test.
A nurse teaches a client who is interested in smoking cessation. Which statements would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Find an activity that you enjoy and will keep your hands busy.”
b. “Keep snacks like potato chips on hand to nibble on.”
c. “Identify a consequence for yourself in case you backslide.”
d. “Drink at least eight glasses of water each day.”
e. “Make a list of reasons you want to stop smoking.”
f. “Set a quit date and stick to it.”
ANS:A,D,E,F
The nurse would teach a client who is interested in smoking cessation to find an activity that
keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight
glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit
date and stick to it. The nurse would also encourage the client not to be upset if he or she
backslides and has a cigarette but to try to determine what conditions caused him or her to
smoke.
A nurse is assessing a client’s history of particular matter exposure. What questions are
consistent with the I PREPARE tool? (Select all that apply.)
a. Investigate all history of known exposures.
b. Determine if breathing problems are worse at work.
c. Ask the client what type of heating is in the home.
d. Gather details about the geographic location of the client’s home.
e. Have client list all previous jobs and work experiences.
f. Assess what hobbies the client and family enjoy.
ANS: A, B, C, D, E, F
All questions are appropriate for the I PREPARE model of particulate matter exposure. The R
and final E stands for resources/referrals and educate.
A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations
ANS: B, D, E
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough,
and pain that is worse at the end of inhalation and the end of exhalation on the affected side.
Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected
side of the chest that does not move in and out with respirations. Purulent sputum is a
symptom of infection.
A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy
procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)
a. Provide a clear liquid breakfast.
b. Verify that the informed consent was obtained.
c. Document the client’s allergies.
d. Review laboratory results.
e. Hold the client’s bronchodilator.
f. Monitor the client for at least 24 hours afterwards.
ANS: B, C, D, F
Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep
the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent
aspiration, document allergies, and review laboratory results including complete blood count
and bleeding times. There is no reason to hold the client’s bronchodilator prior to this
procedure. The nurse will monitor the client at least every 4 hours for 24 hours.
A nurse caring for a client removes the client’s oxygen as prescribed. The client is now
breathing what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
Oxygen content of atmospheric or “room air” is about 21%.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is
the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure that informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be
on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required
but do not take priority.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
a. Assess the client’s oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the client’s oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client’s bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food particles seen in secretions or
by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a
swallow study will not correct this situation.
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse is
best?
a. Assess the client’s lung sounds.
b. Assign a different AP to the client.
c. Report the AP to the manager.
d. Request thicker liquids for meals.
ANS: A
The best action is to check the client’s oxygenation because he or she may have aspirated.
Once the client has been assessed, the nurse would notify the primary health care provider of
possible aspiration and would consult with the registered dietitian about appropriately
thickened liquids. The UAP should have reported the incident immediately, but addressing
that issue is not the immediate priority.
A nurse is providing tracheostomy care. What action by the nurse requires intervention by
the charge nurse?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure injuries and for client safety, when ties are used that must be knotted, the
knot would be placed at the side of the client’s neck, not in back. The other actions are
appropriate.
A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What
action by the student demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction would only be applied while withdrawing the catheter. The other actions are
appropriate.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding
indicates that outcomes for client safety with oxygen therapy are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin
breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with
oxygen therapy are being met. Nutrition and weight are not related to using oxygen.
Understanding the need for oxygen is important but would not take priority over a physical
problem.
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy
tube is pulsing with the heartbeat as the client’s pulse is being taken. No other abnormal
findings are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the primary health care provider
immediately.
ANS:D
This client may have a tracheoinnominate artery fistula, which can be a life-threatening
emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is
yet present, the nurse stays with the client and asks someone else to notify the primary health
care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and
applies pressure at the bleeding site. The client will need to be prepared for surgery.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the
nurse best indicates that goals for the client’s decrease in self-esteem are being met?
a. The client demonstrates good understanding of stoma care.
b. The client has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
The client joining a book club that meets outside the home and requires him or her to go out in
public is the best sign that goals for disrupted self-esteem are being met. The other findings
are all positive signs but do not relate to this client problem.
A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse
delegate to assistive personnel (AP)?
a. Apply water-soluble ointment to nares and lips.
b. Periodically turn the oxygen down or off.
c. Replaces the oxygen tubing with a different type.
d. Turn the client every 2 hours or as needed
ANS: A
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and
nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client
is not related to comfort measures for oxygen.
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What
action by the nurse is best?
a. Assess the client’s oxygen saturation and, if normal, turn off the oxygen.
b. Determine if the client can switch to a nasal cannula during the meal.
c. Have the client lift the mask off the face when taking bites of food.
d. Turn the oxygen off while the client eats the meal and then restart it.
ANS:B
Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the
primary health care provider has approved switching to a nasal cannula during meals. If not,
the nurse would consult with the primary health care provider about this issue. The primary
health care provider would need to prescribe discontinuing oxygen if the client’s oxygen
saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the
FiO2 delivered.
A home health nurse is visiting a new client who uses oxygen in the home. For which factors
does the nurse assess when determining if the client is using the oxygen safely? (Select all
that apply.)
a. The client does not allow smoking in the house.
b. Electrical cords are in good working order.
c. Flammable liquids are stored in the garage.
d. Household light bulbs are the fluorescent type.
e. The client does not have pets inside the home.
f. No alcohol-based hand sanitizers are present.
ANS: A, B, C
Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse
would assess if the client allows smoking in the house, whether electrical cords are in good
shape or are frayed, and if flammable liquids are stored (and used) in the garage away from
the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand
sanitizers are permitted.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse
delegate to assistive personnel (AP)? (Select all that apply.)
a. Applying water-soluble lip balm to the client’s lips
b. Ensuring that the humidification provided is adequate
c. Performing oral care with alcohol-based mouthwash
d. Reminding the client to cough and deep breathe often
e. Suctioning excess secretions through the tracheostomy
f. Holding the new tracheostomy tube while the RN changes the ties
ANS: A, D
The AP can perform hygiene measures such as applying lip balm and reinforce teaching such
as reminding the client to perform coughing and deep-breathing exercises. Oral care can be
accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity
is adequate and suctioning through the tracheostomy are nursing functions. When needed, a
second licensed person assists with holding the tracheostomy tube during tie changes; some
hospitals require a second licensed person during the first 72 hours after placement.
A client is being discharged home after having a tracheostomy placed. What suggestions does
the nurse offer to help the client maintain self-esteem? (Select all that apply.)
a. Create a communication system.
b. Don’t go out in public alone.
c. Find hobbies to enjoy at home.
d. Try loose-fitting shirts with collars.
e. Wear fashionable scarves.
ANS:A,D,E
The client with a tracheostomy may be shy and hesitant to go out in public. The client needs
to have a sound communication method to ease frustration. The nurse can also suggest ways
of enhancing appearance so the client is willing to leave the house. These can include wearing
scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good
advice.
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion
ANS: A, B, D, E, F
The older adult is at risk for having impairments in cognition, dexterity, range of motion, and
vision that could limit the ability to perform tracheostomy care and would be assessed. Upper
arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to
the ability to perform self-care.
