Respiratory I
A college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is:
A. Yellow
B. Green
C. Clear
D. Gray
Correct Answer: C. Clear
Normally, nasal drainage in acute rhinitis is clear. Anterior rhinoscopy typically reveals swelling of the nasal mucosa and thin, clear secretions. The inferior turbinates may take on a bluish hue, and cobblestoning of the nasal mucosa may be present. On physical examination, clinicians may notice mouth breathing, frequent sniffling and/or throat clearing, transverse supra-tip nasal crease, and dark circles under the eyes (allergic shiners).
Which of the following ABG abnormalities should the nurse anticipate in a client with advanced COPD?
A. Increased PaCO2
B. Increased PaO2
C. Increased pH
D. Increased oxygen saturation
Correct Answer: A. Increased PaCO2
As COPD progresses, the client typically develops increased PaCO2 levels and decreased PaO2 levels. This results in decreased pH and decreased oxygen saturation. These changes are the result of air trapping and hypoventilation. Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity of disease exacerbation
On auscultation, which finding suggests a right pneumothorax?
A. Bilateral inspiratory and expiratory crackles.
B. Absence of breath sound in the right thorax.
C. Inspiratory wheezes in the right thorax.
D. Bilateral pleural friction rub.
B. Absence of breath sounds in the right thorax
In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse. The degree of collapse determines the clinical presentation of pneumothorax. None of the other options are associated with pneumothorax.
The nurse is caring for a client with a pneumothorax and who has had a chest tube inserted. She notes gentle bubbling in the suction control chamber. What action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician.
C. Check for an air leak because the bubbling should be intermittent.
D. Increase the suction pressure so that the bubbling becomes vigorous.
Correct Answer: A. Do nothing, because this is an expected finding.
Continuous gentle bubbling should be noted in the suction control chamber. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes
A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client?
A. Initiate oxygen therapy and reassess the client in 10 minutes.
B. Draw blood for an ABG analysis and send the client for a chest x-ray.
C. Encourage the client to relax and breathe slowly through the mouth.
D. Administer bronchodilators
Correct Answer: D. Administer bronchodilators.
In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
A. Encourage oral feeding as soon as possible.
B. Develop an alternative communication method.
C. Keep the tracheostomy cuff fully inflated.
D. Keep the patient flat in bed.
B. Develop an alternative communication method.
A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. Assess the effectiveness of nonverbal communication methods. The client may use hand signals, facial expressions, and changes in body posture to communicate with others. However, others may have difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed for effectiveness and altered as necessary.
An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she developed a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?
A. It is likely that the client is developing a secondary bacterial pneumonia.
B. The assessment findings are consistent with influenza and are to be expected.
C. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions
D. The client has not been taking her decongestants and bronchodilators as prescribed.
A. It is likely that the client is developing a secondary bacterial pneumonia.
Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection that is not consistent with a diagnosis of influenza.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
A. Monitor fluctuations in the water-seal chamber.
B. Clamp the chest tube once every shift.
C. Encourage coughing and deep breathing.
D. Milk the chest tube every 2 hours
C. Encourage coughing and deep breathing.
When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Assist the patient with splinting painful areas when coughing, deep breathing. Supporting chest and abdominal muscles makes coughing more effective and less traumatic.
Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
A. Call the physician.
B. Place the tube in a bottle of sterile water.
C. Immediately replace the chest tube system.
D. Place a sterile dressing over the disconnection site.
Correct Answer: B. Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. Anchor thoracic catheter to the chest wall and provide an extra length of tubing before turning or moving the patient. Prevents thoracic catheter dislodgement or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.
A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to:
A. Begin mechanical ventilation.
B. Place the client on oxygen.
C. Give the client sodium bicarbonate.
D. Monitor for pulmonary embolism.
Correct Answer: B. Place the client on oxygen
The pH (7.50) reflects alkalosis, and the low PaCO2 indicates the lungs are involved. The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to 95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing
On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as:
A) Wheezing
B) Rales
C) Stridor
D) Crackles
C. Stridor
If a client continues to hypoventilate, the nurse will continually assess for a complication of:
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: A. Respiratory acidosis
Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. The respiratory centers in the pons and medulla control alveolar ventilation. Chemoreceptors for PCO2, PO2, and pH regulate ventilation. Central chemoreceptors in the medulla are sensitive to changes in the pH level. A decreased pH level influences the mechanics of ventilation and maintains proper levels of carbon dioxide and oxygen. When ventilation is disrupted, arterial PCO2 increases and an acid-base disorder develops.
The physician has scheduled a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for his is the:
A. Nonoperative side or back
B. Operative side or back
C. Back only
D. Back or either side.
Correct Answer: B. Operative side or back
Positioning the client on the operative side facilitates the accumulation of serosanguineous fluid. The fluid forms a solid mass, which prevents the remaining lung from being drawn into space. Pneumonectomy is defined as the surgical removal of the entire lung. Extrapleural pneumonectomy is an expanded procedure that also involves resection of parietal and visceral pleura, ipsilateral hemidiaphragm, pericardium, and mediastinal lymph nodes
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A. The system is functioning normally.
B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
Correct Answer: C. The system has an air leak.
Constant bubbling in the chamber indicates an air leak and requires immediate intervention. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system-centered).
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate 24 breaths/min
Correct Answer: A. Stridor
The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Post-extubation stridor is uncommon and seen only in less than 10% of unselected critically ill patients and correlates with increased rates of reintubation, prolonged duration of mechanical ventilation, and longer length of ICU stay. Options B, C, and D are not signs that require immediate notification of the physician.
A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client?
A. Altered nutrition: Less than body requirements related to fatigue.
B. Activity intolerance related to dyspnea.
C. Weight loss related to COPD.
D. Ineffective breathing pattern related to alveolar hypoventilation.
Correct Answer: A. Altered nutrition: Less than body requirements related to fatigue.
The client’s problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Instruct the patient to frequently eat high caloric foods in smaller portions. COPD patients expend an extraordinary amount of energy simply on breathing and require high caloric meals to maintain body weight and muscle mass.
Assessing a client who has developed atelectasis postoperatively, the nurse will most likely find:
A. A flushed face.
B. Dyspnea and pain.
C. Decreased temperature.
D. Severe cough and no pain.
Correct Answer: B. Dyspnea and pain
Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation. Clients become short of breath, have a high temperature, and usually experience severe pain but do not have a severe cough. The shortness of breath is a result of decreased oxygen-carbon dioxide exchange at the alveolar level. Postoperative atelectasis typically occurs within 72 hours of general anesthesia and is a well-known postoperative complication.
A client with a productive cough, chills, and night sweats is suspected of having active TB. The physician should take which of the following actions?
A. Admit him to the hospital in respiratory isolation.
B. Prescribe isoniazid and tell him to go home and rest.
C. Give a tuberculin test and tell him to come back in 48 hours and have it read.
D. Give a prescription for isoniazid, 300 mg daily for 2 weeks, and send him home.
A. Admit him to the hospital in respiratory isolation.
The client is showing s/s of active TB and because of a productive cough is highly contagious. He should be admitted to the hospital, placed in respiratory isolation, and three sputum cultures should be obtained to confirm the diagnosis. After 7 to 10 days, three more consecutive sputum cultures will be obtained. If they’re negative, he would be considered non-contagious and may be sent home, although he’ll continue to take the antitubercular drugs for 9 to 12 months.
A patient sustained a serious crush injury to the neck and had a trach tube placed 3 days ago. As the nurse is performing trach care, the patient suddenly sneezes forcefully and the tube falls out onto the bed linens. What does the nurse do?
A. ventilate the patient with 100% oxygen and notify the provider
B. quickly and gently replace the tube with a clean cannula kept at the bedside
C. quickly rinse the tube with sterile solution and gently replace it
D. Give the patient oxygen; call for assistance and a new tracheostomy kit
B. quickly and gently replace the tube with a clean cannula kept at the bedside
Best practices require that replacement tracheostomy tubes are maintained at the bedside; this includes a tube equal in size and a tube that is one size smaller, along with an intubation tray.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?
A. Continue to suction.
B. Notify the physician immediately.
C. Stop the procedure and reoxygenate the client.
D. Ensure that the suction is limited to 15 seconds.
C. Stop the procedure and reoxygenate the client.
During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
A patient with a diagnosis of pneumonia complains of a new onset of slight shortness of breath. For which of the following assessment findings would the nurse call the primary care provider immediately? (Select all that apply.)
A. The patient is voiding in excessive amounts
B. The patient is sleeping more than usual.
C. There is a pink coloration to the skin.
D. The patient’s secretions are thin and milky colored.
E. The patient thought it was the 3rd instead of the 5th of the month.
B. Indicates lethargy/coma - intermediate to late sign of hypoxia
C. Indicates increased CO2 -- intermediate sign of hypoxia
E. Indicates confusion -- intermediate sign of hypoxia
Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD?
A. Increased anteroposterior chest diameter.
B. Underdeveloped neck muscles.
C. Collapsed neck veins.
D. Increased chest excursions with respiration.
Correct Answer: A. Increased anteroposterior chest diameter.
Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. In addition, coarse crackles beginning with inspiration may be heard.
A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate?
A. “This is an anticipated side-effect of your medication. It should go away in a couple of weeks.”
B. “You are using your inhaler too much and it has irritated your mouth.”
C. “You have developed a fungal infection from your medication. It will need to be treated with an antibiotic.”
D. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”
Correct Answer: C. “You have developed a fungal infection from your medication. It will need to be treated with an antibiotic.”
Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development of oral thrush, a fungal infection. Oral candidiasis (thrush) is another common complaint among users of inhaled corticosteroids. This risk increases in elderly patients and patients who are also taking oral steroids, high dose ICS, or antibiotics.
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
A. Auscultate the client's breath sounds while applying a nasal cannula
B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask
C. Apply a 100% non-rebreather mask while administering high-flow oxygen
D. Replace the obturator while inserting the tracheostomy tube
B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask
Accidental tracheostomy tube decannulation within the first 72 hours of the surgical procedure is considered a medical emergency because the tracheostomy is not mature, and during reinsertion, there is a greater risk for tissue damage and unsuccessful ventilation. If accidental decannulation occurs, the nurse must stay with the patient, call for assistance from respiratory therapy and a healthcare provider, and provide manual ventilation using a manual resuscitation bag with 100% oxygen. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.
After oxygen has been administered, the next priority intervention the nurse would initiate for a patient with a pulmonary embolus is the administration of which of these therapies?
A. Normal saline IV fluid
B. IV heparin
C. Platelet administration
D. Antibiotics for inflammatory fever
B. IV heparin