Noninfectious
upper respiratory
upper respiratory
A patient with severe OSA underwent modified uvulopalatopharyngoplasty (modUPPP) 6 hours ago. The nurse notes the patient is drooling and unable to swallow oral secretions effectively. What is the priority nursing action?
Assess airway patency and notify the surgeon immediately.
Rationale: Drooling and inability to swallow oral secretions indicate potential airway obstruction from postoperative swelling. This is a critical complication requiring immediate intervention. The nurse should assess respiratory effort, pulse oximetry, voice quality, and presence of stridor while preparing to notify the surgeon, as this may indicate the need for emergency airway management.
A patient with severe asthma is prescribed salmeterol (LABA) and uses it during an acute asthma attack for quick relief. What should the nurse teach?
"LABAs cannot stop an acute attack. Use your short-acting beta2-agonist (SABA) like albuterol instead."
Rationale: Long-acting beta2-agonists need time to build up an effect and are useful for preventing attacks, not stopping them. Patients should use SABAs (albuterol, levalbuterol) to relieve acute symptoms. LABAs used alone carry an FDA black box warning due to increased asthma deaths when used as the only therapy.
A nurse is assessing a patient with suspected pneumonia. Which assessment finding indicates the patient may be developing hypoxemia and reduced gas exchange?
The patient is sitting upright, leaning forward with hands on knees in a tripod position.
Rationale: The patient with hypoxia and reduced gas exchange may be uncomfortable in a lying position and will sit upright, balancing with the hands (tripod position). This position allows for maximum chest expansion and use of accessory muscles. Other signs include use of accessory muscles, crackles on auscultation, diminished breath sounds, and increased fremitus over areas of consolidation.
A patient with PE is started on heparin therapy. What is the therapeutic PTT range for this condition?
Answer: 1.5 to 2.5 times the control value.
Rationale: Review the patient's partial thromboplastin time (PTT) before therapy is started and thereafter according to facility policy. Therapeutic PTT values usually range between 1.5 and 2.5 times the control value for PE. Factor anti-Xa levels may be used instead of PTT if the response to unfractionated heparin is insufficient or inappropriate, as heparin primarily acts on Factor Xa.
A patient with COPD demonstrates inhaler use by taking a quick, shallow breath while pressing the canister. What should the nurse teach?
"Take a slow, deep breath while pressing the inhaler, then hold your breath for 10 seconds."
Rationale: Correct inhaler technique is key for successful COPD drug therapy. The nurse should have the patient demonstrate inhaler use at every outpatient interaction, reinforce correct technique, and help acquire the knowledge and skills needed for proper use.
Which statement by a patient preparing for discharge after laryngectomy indicates need for further teaching?
I can take regular showers without any special precautions now."
Rationale: The patient must use a shower shield over the stoma when bathing to prevent water from entering the airway. Water entering the stoma can cause drowning since the trachea opens directly to the outside. Patients should also wear a protective stoma guard during the day for protection.
During an asthma attack, a patient's arterial blood gas shows: PaO2 88 mm Hg, PaCO2 48 mm Hg. What does the elevated PaCO2 indicate?
arbon dioxide retention indicating worsening respiratory status and potential respiratory failure.
Rationale: Early in an asthma attack, PaCO2 decreases as the patient hyperventilates. Rising PaCO2 later in an episode indicates carbon dioxide retention and respiratory muscle fatigue—a sign of deteriorating condition requiring immediate intervention.
A patient has a tuberculin skin test (TST) with 12 mm of induration at 48 hours. What does this result indicate?
Exposure to TB or presence of inactive (dormant) disease, not active disease.
Rationale: An area of induration (localized swelling with hardness) measuring 10 mm or greater indicates exposure to and possible infection with TB. In adults with reduced immunity, induration of 5 mm is positive. A positive reaction indicates exposure to TB or inactive disease, NOT active disease. Additional testing is required to determine whether the patient has latent TB infection or active disease. Note: The BCG vaccine can cause a positive skin test for up to 10 years.
What patient education should be provided to enhance lung expansion in acute respiratory failure?
Answer: Teach deep breathing and coughing techniques, and proper use of incentive spirometry and inhalers if indicated.
Rationale: Teaching the patient about the need for deep breathing and coughing further enhances lung expansion and decreases breathing effort. Proper instruction on incentive spirometry and inhaler use supports improved gas exchange. Oxygen therapy should be administered and oxygen saturation (SaO₂) monitored to determine effectiveness.
A patient's chest tube accidentally becomes dislodged. What should the nurse do immediately?
Cover and occlude the insertion site immediately with sterile gauze.
Rationale: Sterile gauze should be kept at the bedside specifically for this emergency. Occluding the site prevents air from entering the pleural space. Padded clamps should also be kept at bedside for use if the drainage system is interrupted. The collection device must remain below chest level to allow gravity drainage.
A 58-year-old male patient presents with painless hoarseness that has persisted for 3 weeks. He has a 40 pack-year smoking history and drinks 3-4 alcoholic beverages daily. What is the priority nursing action?
Recommend immediate evaluation for laryngeal cancer.
Rationale: Any adult with hoarseness, mouth sores, or a neck lump lasting more than 2 weeks should be evaluated for laryngeal cancer. This patient has multiple risk factors: tobacco use (major risk factor), alcohol use (major risk factor), male gender, and age over 50. Painless hoarseness occurs when tumor size prevents vocal cords from coming together for normal speech.
A patient with COPD is receiving oxygen at 6 L/min via nasal cannula and becomes increasingly lethargic. What should the nurse do first?
Check oxygen saturation and ABG values, then titrate oxygen to maintain SpO2 between 88-92%.
Rationale: Administering oxygen to correct hypoxemia is priority, but the nurse must monitor for CO2 retention. All hypoxic patients should receive oxygen at rates to reduce hypoxia and bring SpO2 to 88-92%. Titrate oxygen slowly and monitor ABG values frequently. The typical flow is 2-4 L/min via nasal cannula or up to 40% via Venturi mask.
A patient with TB is prescribed the traditional 6-9 month regimen. Which four first-line drugs are typically included?
Answer: Isoniazid, rifampin, pyrazinamide, and ethambutol.
Rationale: Traditional treatment regimens are 6 to 9 months in duration and include these four first-line drugs. Multiple-drug regimens kill or suppress the growth of organisms as quickly as possible and reduce the emergence of drug-resistant organisms. In 2022, a shortened 4-month regimen was approved using isoniazid, rifapentine, moxifloxacin, and pyrazinamide.
A patient undergoes a thoracentesis. What symptoms indicate the patient may have developed a pneumothorax?
Answer: Reduced breath sounds on affected side, hyperresonance on percussion, prominence of affected side, tracheal deviation away from midline, sudden sharp chest pain, feeling of air hunger, dyspnea, and tachypnea.
Rationale: After thoracentesis, monitor vital signs and listen to the lungs for absent or reduced sounds on the affected side. Teach the patient about symptoms of pneumothorax (partial or complete collapse of the lung), which can occur within the first 24 hours. Instruct the patient to go to the nearest emergency department immediately if these symptoms occur.
A nurse is caring for a hospitalized patient with active TB. What infection control measures are required?
Answer: Airborne Precautions in a well-ventilated room with at least six air exchanges per minute; all healthcare workers must use a personal respirator (N95).
Rationale: The hospitalized patient with active TB requires Airborne Precautions in a well-ventilated room with at least six exchanges of fresh air per minute. All healthcare workers must use a personal respirator when caring for the patient, along with Standard Precautions. Airborne Precautions are discontinued when the patient is no longer contagious.
A patient arrives at the emergency department with an anterior nosebleed that started 20 minutes ago. What is the priority nursing assessment?
Document the amount and color of blood, take vital signs, and assess for signs of airway compromise.
Rationale: Initial assessment should include vital signs to evaluate hemodynamic stability, documentation of bleeding characteristics, and airway assessment. The nurse should also ask about the number, duration, and causes of previous bleeding episodes, history of nasal or facial trauma, current medications (especially anticoagulants), and family history of bleeding disorders.
A patient with CF develops increased chest congestion, bloody sputum, decreased SpO2, and a 10% decrease in FEV1. What does this indicate and what is the priority intervention?
CF exacerbation requiring intensified therapy with airway clearance techniques four times daily, bronchodilators, mucolytics, steroids, and a 14-21 day course of antibiotics.
Rationale: Exacerbation symptoms include increased chest congestion, reduced activity tolerance, increased/new crackles, bloody or purulent sputum, decreased appetite, weight loss, fatigue, decreased SpO2, and chest retractions. Management focuses on airway clearance, increased gas exchange, and antibiotic therapy. Supplemental oxygen is prescribed based on SpO2 levels.
Why are combination antibiotics used for suspected inhalation anthrax rather than a single agent?
Answer: Organisms grown for bioterrorism may have been altered to be resistant to standard antibiotics.
Rationale: Combination therapy with drugs like ciprofloxacin, doxycycline, levofloxacin, moxifloxacin, and clindamycin is necessary because bioterrorism-related anthrax organisms may be engineered for antibiotic resistance. Multiple drugs increase the likelihood of effective treatment.
What assessment findings indicate a patient may be aspirating?
Answer: Wheezes on lung auscultation, dyspnea, and excessive secretions.
Rationale: Assess for dyspnea resulting from obstruction or excessive secretions. Auscultate the lungs for adventitious sounds, such as wheezes caused by aspiration. These findings indicate material may have entered the airway, requiring immediate intervention.
Where should chest tubes be positioned for optimal drainage?
Answer: The air drainage tube is placed near the front lung apex (third intercostal space), and the liquid drainage tube is placed on the side near the base of the lung (sixth intercostal space).
Rationale: The tip of the tube used to drain air is placed near the front lung apex. The tube that drains liquid is placed on the side near the base of the lung. This positioning uses gravity and anatomy to optimize drainage of both air and fluid.
A patient returns home after rhinoplasty with nasal packing in both nostrils. Which statement indicates the patient needs further teaching?
"I can blow my nose gently if I need to clear it."
Rationale: Patients must avoid blowing the nose, sniffing upward, or sneezing with the mouth closed for the first few days after packing removal to prevent bleeding. They should also avoid forceful coughing or straining during bowel movements, and avoid aspirin and NSAIDs.
A nurse notices that tidaling has stopped in the water-seal chamber of a patient's chest tube drainage system. What are two possible causes?
The lung has fully reexpanded OR there is an obstruction in the chest tube (kinked or blocked).
Rationale: Tidaling is the normal rise (2-4 inches during inhalation) and fall (during exhalation) of water in the water-seal chamber. Absence of tidaling may indicate successful lung reexpansion or a problem like obstruction. The nurse must assess the patient and system to determine the cause.
What infection control measure is most important when caring for a patient on mechanical ventilation to prevent VAP?
Answer: Strict adherence to hand hygiene and Standard Precautions; proper handling of ventilator equipment and supplies.
Rationale: Organisms from invasive devices, equipment and supplies, or other people can invade the body and cause pneumonia. Preventing contamination through proper infection control practices, including hand hygiene and appropriate handling of respiratory equipment, is essential to prevent VAP.
How often should oral suctioning be performed after lung surgery?
Answer: Only as needed, not routinely.
Rationale: Perform oral suctioning only as needed after respiratory surgery. Routine suctioning can cause trauma and stimulate excessive secretion production. The patient's clinical assessment should guide the need for suctioning.
What monitoring parameters are essential for patients with ARDS?
Answer: Monitor ABGs, oxygen saturation, vital signs, lung sounds, and respiratory status at least every 1-2 hours. Document dyspnea, dysrhythmias, and signs of hypoxemia.
Rationale: Monitor the patient continually for any changes in status. Check vital signs, lung sounds, and cardiac and respiratory status frequently. Monitor ABGs and oxygen levels to identify patients at risk for complications and adjust therapy accordingly.